[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
                  ADDRESSING DISPARITIES IN HEALTH AND 
                      HEALTHCARE: ISSUES OF REFORM 

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 10, 2008

                               __________

                           Serial No. 110-86

                               __________

         Printed for the use of the Committee on Ways and Means

                               ----------
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                      COMMITTEE ON WAYS AND MEANS

                 CHARLES B. RANGEL, New York, Chairman

FORTNEY PETE STARK, California       JIM MCCRERY, Louisiana
SANDER M. LEVIN, Michigan            WALLY HERGER, California
JIM MCDERMOTT, Washington            DAVE CAMP, Michigan
JOHN LEWIS, Georgia                  JIM RAMSTAD, Minnesota
RICHARD E. NEAL, Massachusetts       SAM JOHNSON, Texas
MICHAEL R. MCNULTY, New York         PHIL ENGLISH, Pennsylvania
JOHN S. TANNER, Tennessee            JERRY WELLER, Illinois
XAVIER BECERRA, California           KENNY HULSHOF, Missouri
LLOYD DOGGETT, Texas                 RON LEWIS, Kentucky
EARL POMEROY, North Dakota           KEVIN BRADY, Texas
STEPHANIE TUBBS JONES, Ohio          THOMAS M. REYNOLDS, New York
MIKE THOMPSON, California            PAUL RYAN, Wisconsin
JOHN B. LARSON, Connecticut          ERIC CANTOR, Virginia
RAHM EMANUEL, Illinois               JOHN LINDER, Georgia
EARL BLUMENAUER, Oregon              DEVIN NUNES, California
RON KIND, Wisconsin                  PAT TIBERI, Ohio
BILL PASCRELL, JR., New Jersey       JON PORTER, Nevada
SHELLEY BERKLEY, Nevada
JOSEPH CROWLEY, New York
CHRIS VAN HOLLEN, Maryland
KENDRICK MEEK, Florida
ALLYSON Y. SCHWARTZ, Pennsylvania
ARTUR DAVIS, Alabama

             Janice Mays, Chief Counsel and Staff Director

                  Brett Loper, Minority Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                FORTNEY PETE STARK, California, Chairman

LLOYD DOGGETT, Texas                 DAVE CAMP, Michigan
MIKE THOMPSON, California            SAM JOHNSON, Texas
RAHM EMANUEL, Illinois               JIM RAMSTAD, Minnesota
XAVIER BECERRA, California           PHIL ENGLISH, Pennsylvania
EARL POMEROY, North Dakota           KENNY HULSHOF, Missouri
STEPHANIE TUBBS JONES, Ohio
RON KIND, Wisconsin


Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Ways and Means are also published 
in electronic form. The printed hearing record remains the official 
version. Because electronic submissions are used to prepare both 
printed and electronic versions of the hearing record, the process of 
converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.




























                            C O N T E N T S

                               __________

                                                                   Page

                               WITNESSES

The Honorable Donna M. Christensen, Delegate to Congress from the 
  United States Virgin Islands...................................     7
The Honorable Hilda L. Solis, Representative in Congress from the 
  State of California............................................    16
The Honorable Madeleine Z. Bordallo, Delegate to Congress from 
  Guam...........................................................    21
The Honorable Jerry Moran, a Representative in Congress from the 
  State of Kansas................................................    26
Marsha Lillie-Blanton, DrPH, Senior Advisor on Race, Ethnicity 
  and Healthcare, Kaiser Family Foundation.......................    39
Mohammad Akhter, M.D., MPH, Executive Director, National Medical 
  Association....................................................    44
Deeana Jang, J.D., Policy Director, Asian & Pacific Islander 
  American Health Forum..........................................    50
Anthony B. Iton, M.D., J.D., MPH, Director of Public Health & 
  Health Officer, Alameda County, California.....................    58
Sally Satel, M.D., Resident Scholar, American Enterprise 
  Institute......................................................    65
Michael A. Rodriguez, M.D., MPH, Associate Professor and Vice 
  Chair of Research, UCLA, Department of Family Medicine.........    69

                       SUBMISSIONS FOR THE RECORD

The Honorable Hilda L. Solis, Statement..........................    87
America's Health Insurance Plans, Statement......................    94
American College of Physicians, Statement........................    97
American Dental Education Association, Statement.................   100
American Dental Hygienists' Association, Statement...............   103
American Hospital Association, Statement.........................   109
Glenn Flores, M.D., Statement....................................   111
National Black Nurses Association, Statement.....................   118
National Business Group on Health, Statement.....................   121
National Council of Urban Indian Health, Statement...............   122
Papa Ola Lokahi, Statement.......................................   126
Special Olympics International, Statement........................   129


                  ADDRESSING DISPARITIES IN HEALTH AND
                      HEALTHCARE: ISSUES OF REFORM

                              ----------                              


                         TUESDAY, JUNE 10, 2008

             U.S. House of Representatives,
                       Committee on Ways and Means,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 10:07 a.m., in 
room 1100, Longworth House Office Building, Hon. Fortney Pete 
Stark [Chairman of the Subcommittee] presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                         SUBCOMMITTEE ON HEALTH

                                                CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
June 03, 2008
HL-26

                  Addressing Disparities in Health and
                     Healthcare: Issues for Reform

    House Ways and Means Health Subcommittee Chairman Pete Stark (D-CA) 
announced today that the Subcommittee on Health will hold a hearing on 
disparities in health and access to care as part of the on-going health 
reform hearing series. The hearing will take place at 10:00 a.m. on 
Tuesday, June 10, 2008, in the main committee hearing room, 1100 
Longworth House Office Building.
      
    In view of the limited time available to hear witnesses, oral 
testimony at this hearing will be from invited witnesses only. However, 
any individual or organization not scheduled for an oral appearance may 
submit a written statement for consideration by the Committee and for 
inclusion in the printed record of the hearing.
      

BACKGROUND:

      
    Over the years, numerous studies and reports have documented the 
disparities that exist in health and access to healthcare for women and 
racial and ethnic minorities in the United States. Despite research on 
the causes of these differences, disparities persist in access to care, 
quality of care, health outcomes, and prevalence of certain diseases 
for particular subpopulations. A host of socioeconomic factors such as 
place of residence, income, education, and insurance status contribute 
to this troubling problem.
      
    Though isolating the precise impact of gender, race, and ethnicity 
is difficult, lack of health insurance coverage is undeniably one of 
the most important barriers affecting access to care and the resulting 
disparities that exist today. A 2007 report published by the Agency for 
Healthcare Research and Quality (AHRQ) found that uninsured individuals 
were six times more likely than insured individuals to be without a 
usual source of care and nearly four times as likely to be without a 
usual source of care for financial reasons\1\
---------------------------------------------------------------------------
    \1\ http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf
---------------------------------------------------------------------------
      
    However, even when people have insurance coverage, both public and 
private, disparities remain. The House-passed CHAMP Act, H.R. 3162, 
attempted to improve the understanding of and address some root causes 
of the persistent disparities in the Medicare population by improving 
data collection across the program, increasing access to culturally and 
linguistically appropriate care, and instituting several demonstration 
projects to address issues affecting vulnerable beneficiary subgroups.
      
    In announcing the hearing Chairman Stark said, ``While we can make 
a big dent in addressing disparities by getting everyone covered, we 
must recognize that these issues transcend access to coverage. We must 
pay special attention to ensure access to care and good outcomes for 
everyone, regardless of race, gender, or ethnicity.''
      
FOCUS OF THE HEARING:
      
    The hearing will focus on issues related to health disparities and 
disparities in access to care, as well as possible solutions to address 
these issues.
      
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
      
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FORMATTING REQUIREMENTS:
      
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materials in alternative formats) may be directed to the Committee as 
noted above.

                                

      
    Chairman STARK. If our guests can find seats, we will 
commence the hearing, the third in the series dealing with 
issues that we may face in healthcare reform in the next 
Congress; and I welcome our colleagues from the Congressional 
Black Caucus, the Hispanic Caucus, the Asian Pacific American 
Caucus and the Rural Caucus, I presume.
    The purpose of the hearing is to learn more about 
healthcare disparities, and there are still some people that 
question whether these disparities exist. Hurricane Katrina 
established that we have a two-tiered healthcare system, if 
anybody else didn't believe that, one for those who are healthy 
and well-insured and have money and one for everybody else. 
Without Katrina, it is clear on a daily basis that minority 
populations are disproportionately represented in the second 
tier of everyone else.
    We could do better; and, as we gear up for health reform, 
we should try and craft solutions that reduce and hopefully 
eliminate healthcare disparities. We must do more than simply 
cover everyone. We should ensure access and the receipt of 
healthcare to be determined by one's healthcare needs and not 
their ability to pay, their place of residence or their skin 
color.
    We have to look at the role that Medicare has played in 
reducing disparities among the elderly and the general 
population and know that universal coverage is a necessary step 
toward eliminating health disparities.
    Before Medicare, minorities age 75 or over had an average 
of 4.8 doctor visits a year compared to 7.5 for their white 
counterparts. By 71, minority beneficiaries saw doctors at a 
rate comparable to the rest of the United States, and Medicare 
helped integrate the healthcare system as a whole which was 
previously segregated, thereby improving access.
    Just as a sidebar, there is absolutely no mention in 
Medicare, either when you sign up for it or in the records we 
keep, that deals with race and ethnicity. That may be a 
problem. But it is an absolutely color, race, religion-blind 
system that basically everyone over 65, I would say, 
participate. Interesting to study that.
    There are other economic factors that drive disparities. 
Good health insurance is the single-most-important variable, 
one affecting access; and the most important thing we can do to 
reduce disparities is to get everyone covered. However, we 
shouldn't stop there. Data from public and private programs 
show that disparities persist even when coverage is available, 
which is a reasonable doubt--I have lost my pages here.
    Just last week, the Robert Wood Johnson Foundation released 
new research showing that the quality of care and health 
outcomes does vary dramatically depending on race; and that is 
not acceptable. Last year's CHAMP Act included a number of 
provisions to combat these problems in Medicare, and I am 
pleased to see that Chairman Bachus may have included some of 
these provisions in the legislation that will be before the 
Senate this week.
    But there is more to be done. We will hear from our 
colleagues, from the Congressional Black Caucus, the 
Congressional Hispanic Caucus, the Asian Pacific Caucus; and we 
will discuss these issues generally with a mention of the 
provisions of H.R. 3014, the Health Equity and Accountability 
Act, that are, at least those provisions, under our 
jurisdiction and a discussion of the CHAMP Act's disparity 
provisions, which are still pending in the Senate.
    The witnesses on the second panel will give us a broad 
overview of health and healthcare disparities and offer 
promising approaches to address them. The panel includes health 
services research experts and those with firsthand experience 
as physicians and administrators. Again, I want to thank the 
witnesses today.
    And I want to add one other comment for this panel and the 
subsequent panels, and the Members of this Subcommittee I think 
have heard me suggest this often. We don't--and I don't--let's 
just say as a matter of my policy, to the extent that I can 
direct the policy on this Committee--try to make decisions in 
this Committee that will affect various procedures, drugs or 
dollar payments for specific procedures.
    We have MedPAC. We have CMS with experts. We aren't expert. 
Most of the procedures and drugs we can't pronounce or spell, 
and we don't have any idea what they do. And if we once started 
to say, okay, Doc, we are going to pay X dollars for this 
procedure, the line outside our office doors would go around 
the block three times for other doctors wanting to get the 
price of their procedures raised or manufacturers of exotic new 
equipment wanting us to include it in Medicare. I think you, 
our colleagues in the House and the public are better served by 
our defaulting to professionals to advise us and for us to deal 
with broader payment structures to the providers.
    Because there will be discussions of--for example, I think 
it is known that African Americans have a higher rate of 
diabetes. I am not sure this Committee should get into the 
issue of whether we should pay more for certain diabetic 
procedures or not. I think the fact that we--if we recognize 
that and can ask the public insurance companies, who are the 
only ones we have any control over, to take that into account 
and ask for studies, that is about as far as we go. And I just 
wanted to add that as kind of a limitation that I think we have 
in our jurisdiction.
    Mr. Camp, would you like to address the panel?
    Mr. CAMP. Yes. Thank you, Mr. Chairman; and I also want to 
welcome all of our witnesses and thank them for coming. I look 
forward to hearing your testimony today.
    It is an unfortunate fact in this country that some people 
don't have health insurance, and in previous hearings we have 
talked about who these people are. And today we will hear 
testimony about why some people have better access to quality 
care than others, and we will find discrepancies and treatments 
and outcomes do exist amongst certain populations. This 
morning, several factors will be dissected and their role in 
contributing to health disparities will be discussed.
    The Robert Wood Johnson Foundation released a study last 
week that examined geographical and racial disparities within 
the Medicare Program. This study found that, on a variety of 
quality indices, African Americans are less likely to receive 
recommended care than whites within a given region. However, 
the most striking disparities are found when comparing results 
across States.
    For example, 72 percent of African American women in 
Medicare in Massachusetts received mammograms, while just 48 
percent received them in California. Also, in all but two 
States, African American diabetics are less likely than whites 
to receive annual hemoglobin testing. But 88 percent of African 
Americans in Massachusetts received the screening, compared to 
just 66 percent of those living in Colorado.
    It is clear having health insurance, even Medicare, will 
not solve the disparities that exist within the healthcare 
system.
    We also need to address the variations in medical practice 
and spending. In the time remaining, I do want to emphasize one 
contributor that I believe should not be overlooked, and that 
is a person's geographic location. I want to highlight this 
area because I represent a large rural district. I routinely 
hear from constituents with difficulty obtaining needed 
healthcare because of a dwindling number of healthcare 
providers in their communities. For those with chronic 
conditions, it can be an incredible burden to follow prescribed 
treatment plans when specialists are not local or are unable to 
travel to see their patient in their home. Health disparities 
as they relate to race and ethnicity are very important, and I 
wanted to bring attention to the fact that disparities exist 
across rural areas as well.
    I thank the chairman for calling this important hearing, 
and I look forward to working with him in a bipartisan manner 
to address these critical issues.
    Thank you. I yield back.
    Mrs. JONES. Mr. Chairman?
    Chairman STARK. Yes, Mrs. Tubbs-Jones.
    Mrs. JONES. I would like unanimous consent to make a 
statement, please.
    Chairman STARK. Absolutely. Who would dare object to that 
request?
    Mrs. JONES. I don't know, Mr. Chairman. I knew you 
wouldn't, though. That is why I love you.
    Thank you. Mr. Chairman----
    Mr. CAMP. Me neither.
    Mrs. JONES. A short one.
    I just want to, first of all, thank you for hosting this 
hearing. Throughout the time that I have been on this 
Committee, it has been an issue that has been very, very 
important to me and more important to--as important to my 
predecessor, Honorable Congressman Louis Stokes. I stand on his 
shoulders trying to make sure that we continue to address the 
issue of health disparities.
    I won't try to go into a diatribe or anything like that. 
There are a lot of issues that we must focus on in order for us 
to assure that people, regardless of their race, color, sex, 
religion, et cetera, et cetera, have access to healthcare. And 
it is clear with all the studies that have been presented that, 
even with the same kind of healthcare coverage, there is a 
disparity in the access to that care, no matter where you 
compare throughout the country; and we have to be careful to 
compare Massachusetts with the rest of the world in terms of 
the delivery of healthcare.
    I thank you so very much for focusing on this issue, and I 
appreciate the opportunity for my colleagues who have a lot of 
experience and background in the area to be able to address 
you. Thank you very much, Mr. Chairman.
    Chairman STARK. If there are no other statements, I am 
going to recognize the four Members before us and from left to 
right. The first will be the Honorable Donna M. Christensen, a 
delegate to the Congress from the United States Virgin Islands, 
a physician and a Member. She will be followed by the Honorable 
Hilda Solis from the wonderful State of California; Madeleine 
Bordallo, a delegate from Guam; and Jerry Moran, a 
representative from the State of Kansas, who seemed to have 
avoided tornadoes in this last week and everybody else got 
them. Right?
    So, Donna, if you would like to lead off, and we will just 
go down the line. The light will go on for 5 minutes. Without 
objection, your prepared testimony will appear in the record in 
its entirety; and we will get a chance after--you want to 
summarize your statements or expand on them--to find out more 
from you during the inquiry period.
    Donna, proceed.

   STATEMENT OF THE HON. DONNA M. CHRISTENSEN, A DELEGATE TO 
       CONGRESS FROM THE TERRITORY OF THE VIRGIN ISLANDS

    Mrs. Christensen. Thank you. Good morning, Chairman Stark, 
Ranking Member and Members of the Subcommittee.
    This is a historic and very important hearing on an issue 
of grave concern; and on behalf of my colleagues in the 
TriCaucus, some of whom you will hear from this morning, who 
have been seeking a hearing on this issue for a long time and 
the millions of racial and ethnic minorities who are in poorer 
health because of these disparities, I sincerely thank and 
applaud you for this hearing. And I also want to thank my 
colleague, Congresswoman Stephanie Tubbs-Jones, for her 
leadership as well.
    The central core of my testimony today, which is very much 
abbreviated, is that health disparity elimination must be an 
integral component of healthcare reform. And I also wanted to 
make sure that the Subcommittee understands that the poor 
health outcomes of minorities adversely impacts not just ours 
but the health of everyone else in this country. It is also the 
racial and ethnic health disparities, infant and maternal 
mortality, to name just two, in African Americans, that are 
responsible for our embarrassingly dismally national health 
indicators compared to other countries in the world. Closing 
these and other gaps will improve healthcare for everyone in 
the country, improve our world standing and also reduce the 
cost of healthcare. We therefore owe it to our fellow 
Americans, all of them, to eliminate the racial, ethnic, rural 
and gender health disparities that have plagued this country 
for too long.
    This hearing is a good first step. Passing the disparities 
provisions of CHAMP would be another. And while the great 
success achieved with the passage of CHAMP in the House was 
unfortunately short-lived, it nonetheless started a process 
that brought us here today where racial and ethnic health 
disparities are front and center in the work of this very 
important Subcommittee.
    And before I turn to the three provisions of H.R. 3014, it 
is also important to underscore that health or the lack of it 
does not occur in a vacuum and to recognize the important roles 
that the lack of universal coverage and the social determinants 
of health play.
    This bill, the healthcare Equity and Accountability Act 
which the TriCaucus has introduced in the last three 
Congresses, was developed with broad input both on and off the 
Hill and with a comprehensive approach. Additionally, it tracks 
key recommendations of the Institute of Medicine report on 
equal treatment.
    It is our position that H.R. 3014, introduced by my 
colleague Congresswoman Solis, even though many of the 
provisions are not under the purview of the Subcommittee, 
should be the foundation upon which healthcare reform meets the 
health and healthcare challenges of millions of racial and 
ethnic minorities, women and rural populations.
    The first issue I want to raise from the bill is the need 
for health workforce diversity. At the outset, let me say that 
the only way to truly achieve cultural and linguistic 
competency in healthcare is to increase and dramatically so the 
number of minority health providers at all levels.
    Studies indicate that racial and ethnic minority healthcare 
providers are more likely to serve racial and ethnic minorities 
and other underserved communities. Additionally, providers of 
the same background are more likely to be able to bridge the 
gaps and the dynamics of the patient-provider relationship, 
which translates into more trust and better outcomes.
    Because of poor policy and budget priorities, racial and 
ethnic minority providers are grossly underrepresented across 
all aspects of the U.S. healthcare system. Together, African 
Americans, Hispanic Americans, Asians and American Indians make 
up only 9 percent of our nurses, 6 percent of our physicians 
and 5 percent of our dentists; and racial and ethnic minorities 
make up less than 10 percent of baccalaureate nursing, 8.6 
percent of dental school and only 4.2 percent of medical school 
faculties.
    So the larger healthcare reform dialog must address these 
severe deficiencies. Without diversity within our Nation's 
healthcare system, millions of innocent, hard-working Americans 
will continue to suffer poorer health outcomes and a lower 
quality of life and be at risk for premature, preventible 
death. Hopefully, in the next panel or in the question period, 
the issue of disparate treatment of providers in communities of 
color by CMS will be raised as well as the need for incentives 
to providers serving in high-health-disparity communities.
    The next issue is accountability. Critical to the health 
disparity elimination and also to healthcare reform is 
establishing accountability and evaluation as well as 
coordination of effort in the elimination of health 
disparities. The Health Equity and Accountability Act in that 
bill would not only work to strengthen and expand existing 
entities, such as the Office of Minority Health at the 
Department of Health and Human Services and the National Center 
on Minority Health and Health Disparities Research at NIH, but 
we also propose the creation of offices of minority health 
within CMS and FDA and to create an Office of Health 
Disparities in the Office of Civil Rights at the Department. 
These offices would help to ensure that Federal efforts and 
Federal resources are better coordinated and more effective.
    Third, I want to address the need for community centered 
and comprehensive approaches to eliminating health disparities. 
Our proposal for health empowerment zones, which enjoyed broad 
and strong support in the health advocacy community, should 
resonate in this Committee which created health economic 
empowerment zones. They are included in H.R. 3014 as well as in 
a stand-alone bill. These zones leverage expertise at the 
community level as well as existing resources across all 
Federal agencies to implement health disparity elimination 
plans developed by the impacted communities with technical 
assistance provided by the Department. Fully engaging the 
community is essential. Not doing so is what I believe the 
chief reason that prior efforts have been unsuccessful.
    In closing, no discussion on health disparities before this 
Subcommittee would be complete without including health 
disparity elimination within the Medicare population, including 
the health and quality of healthcare for those with end-stage 
renal disease, a disease that has a disproportionate impact on 
African Americans.
    Additionally, while my position agrees with that stated by 
the chairman earlier and remains that it is not good policy to 
legislate medical practice, as the Subcommittee and the 
Committee decides to move forward with proposed legislation I 
urge doing so with provisions that acknowledge the differences 
between small and large dialysis facilities and that factors 
like race, ethnicity and geography affect the needs of many 
patients.
    In this case, one size does not fit all; and so we hope 
that whatever approach you take would allow for the case-by-
case adjustments necessary to preserve the health and wellness 
of the millions of Americans, a disproportionate number of 
which are African American as well as other racial and ethnic 
minorities and members of rural communities.
    In closing, I want to again thank Chairman Rangel, Mr. 
Stark, Ranking Member Camp and everyone else who made this 
hearing possible.
    Chairman STARK. Donna, thank you very much.
    [The prepared statement of Mrs. Christensen follows:]
 Statement of The Honorable Donna M. Christensen, Delegate to Congress 
                 from the United States Virgin Islands

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman STARK. Hilda Solis.

   STATEMENT OF THE HON. HILDA L. SOLIS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. SOLIS. Thank you, Mr. Chairman and Ranking Member Camp 
and my colleagues. I want to thank you for inviting me here to 
present what we believe is one of the most important healthcare 
access issues of our time.
    Chairman Stark, you especially are to be commended for your 
leadership in bringing the attention here to the Congress to 
discuss healthcare disparities in communities of color; and I 
am pleased to be here along the side of two very hard-working 
Members of Congress that have been working on this issue for a 
number of years, Donna Christensen and, of course, Ms. 
Bordallo.
    I am proud to serve as Chair of the Congressional Hispanic 
Caucus Taskforce on Health and the Environment and as a Member 
of the Energy and Commerce Committee on the Health 
Subcommittee.
    Although there have not been any hearings on healthcare 
disparity since 2000, we know that communities across the 
country have worked on these issues for many years. 
Unfortunately, our most vulnerable underserved populations are 
left behind in health policy.
    Latinos, you know, are the fastest-growing ethnic minority 
population in the country. We make up 14 percent of the 
population, more than 42 million people across this country. 
Thirty-four percent of Latinos are uninsured. According to a 
study of 2007, the National healthcare Disparities Report, 
Latinos fared worse than non-Hispanic whites for core 
measurements on healthcare access and quality.
    The growing diversity of our country means that patients 
encounter barriers to receiving optimal healthcare services. 
Currently, nearly 52 million people, or more than 19 percent of 
the U.S. population, speak also a language other than English 
at home. And in my district in East Los Angeles and the San 
Gabriel Valley, about 60 percent of the population there are 
Latino, and approximately 20 percent are Asian Pacific 
Islander. Sixty-eight percent speak a language other than 
English at their home.
    Cultural and linguistic barriers contribute to reduced 
quality of care, adverse healthcare outcomes and increased 
racial and ethnic disparities. Just as an example, limited 
English proficient individuals are less likely to understand 
their medication instructions, less likely to use primary and 
preventive care, and more likely to seek care in an emergency 
room.
    This is also why I support funding for outreach efforts by 
persons such as community health workers. In our community, 
they are known as promotoras. Community healthcare workers are 
known to work and help enroll underserved populations in health 
insurance programs and engage in health promotion and 
prevention. Through their efforts, they can help reduce the 
burden of asthma, diabetes, HIV and AIDS awareness in many 
communities of color.
    Given the existing health inequities of our healthcare 
system, we produced H.R. 3014, the Health Equity and 
Accountability Act. Among other things, the legislation would 
create a Medicare demonstration project examining access to 
care, costs and health outcomes for all beneficiaries. I am 
proud that we have the support of more than 100 Members of 
Congress and more than 300 organizations.
    And I would like to ask the Committee if I could submit 
this letter for the record.
    Chairman STARK. Without objection.
    [The information follows:]
    ******** COMMITTEE INSERT ********
    Ms. SOLIS. Several provisions of H.R. 3014 have been 
referred to this Committee. And I stated in my letter addressed 
to Chairman Rangel and Ranking Member McCrery on October 23, 
2007, I am eager to work with each and every one of you on 
these provisions. Improving access to health insurance, 
including Medicare, is a key part of reducing inequities in our 
healthcare system. However, efforts that only address access to 
insurance are not the solution for our ills.
    The Institute of Medicare found large disparities among 
Medicare beneficiaries. Spanish speakers, as an example, 
enrolled in Medicare managed care plans have more difficulties 
with provided communication and timeliness of care when 
compared to non-Spanish speakers.
    I believe Medicare, as the leading purchaser of healthcare, 
has the opportunity and responsibility to reduce racial and 
ethnic health disparities; and I am pleased that some of H.R. 
3014's provisions were included in the CHAMP Act of 2007. We 
worked very hard to try to bridge the gap between these 
disparities.
    I have urged the inclusion of provisions in legislation 
last fall that would improve low-income Medicare beneficiaries' 
access to services and reduced disparities within Medicare. And 
on June 4, 2008, I led a letter from the Congressional Hispanic 
Caucus asking for inclusion of the same provisions in the 
Medicare package recently developed by the Senate Finance 
Committee. I would like to also insert that letter for the 
record with your permission, Mr. Chairman.
    Chairman STARK. Without objection.
    [The information follows:]
    ******** COMMITTEE INSERT ********
    Ms. SOLIS. I strongly support the Medicare demonstration 
project to improve communication between providers and limited 
English proficient seniors, a study on Medicare patients for 
language services, an Institute of Medicine report on the 
impact of language services on the health of limited English 
proficient beneficiaries and a report on Medicare compliance 
with national standards on culturally and linguistically 
appropriate services.
    I also believe all the culturally and linguistically 
appropriate standards should be adopted by Medicare and other 
healthcare organizations, and I am pleased that Senator Baucus 
recently introduced a Medicare package which includes some of 
those provisions which are necessary to reduce these healthcare 
disparities.
    In closing, I would like to take the opportunity to note 
that our health is the product of our social determinants of 
health, including income, race, education, environment and 
geography. It is my hope that the Congress and future leaders 
will consider how policies impact our health particularly the 
health of vulnerable communities of color, and we will be able 
to hopefully implement such measures as H.R. 3014 to improve 
the quality of healthcare and decrease those inequities that 
exist in this disparate treatment.
    I thank you again for having this hearing, and I commend 
the Members of this Subcommittee.
    I yield back the balance of my time.
    Chairman STARK. Thank you very much.
    [The prepared statement of Ms. Solis follows:]
          Prepared Statement of The Honorable Hilda L. Solis,
        Representative in Congress from the State of California
    Chairman Stark, Ranking Member Camp, and my colleagues, thank you 
for inviting me to testify about the inequities of our healthcare 
system. Chairman Stark, I would especially like to commend you for your 
leadership in bringing attention to disparities in health for 
communities of color.
    I am pleased to be here today with Representatives Christensen and 
Bordallo. We represent the Congressional Hispanic, Black, and Asian 
Pacific American Caucuses, known collectively as the TriCaucus.
    As the Chair of the Congressional Hispanic Caucus Task Force on 
Health and the Environment and as a Member of the Energy and Commerce 
Subcommittee on Health, I am working to improve the health of all 
individuals, particular communities of color. Latinos are the fastest-
growing racial/ethnic group in the United States. We make up 14 percent 
of the population, which is more than 42 million people across the 
nation, yet we also suffer from the highest uninsured rates in the 
country. According to data released by the Census Bureau in 2007, 34.1 
percent of Latinos (more than 15 million) are uninsured, compared with 
20.5 percent of African Americans, 15.5 percent of Asian/Pacific 
Islanders, and 10.8 percent of non-Hispanic Whites.
    As we move forward toward national health reform, we must not leave 
behind our most vulnerable and underserved populations. Unfortunately, 
current programs do leave behind our most vulnerable and underserved 
populations.
    Communities of color often suffer from higher rates of death and 
disease. The Agency for Healthcare Research and Quality's 2007 National 
Healthcare Disparities Report (NHDR) finds that ``Overall, disparities 
in quality and access for minority groups and poor populaitons have not 
been reduced since the first NHDR.'' According to the 2007 NHDR, 
Latinos fared worse than non-Hispanic Whites for seven of eight core 
measurements of healthcare access and for 23 or 38 core report measures 
of quality.
    The growing diversity of our country means that many patients 
encounter barriers to receiving optimal healthcare. By 2050, it is 
projected that members of racial or ethnic ``minority'' groups will 
together account for almost half of the U.S. population. Currently, 
nearly 52 million people, or more than 19 percent of the U.S. 
population, speak a language other than English at home. There are also 
a substantial number of individuals who are not proficient in the 
English language. According to the 2006 American Community Survey, 
almost 11 million U.S. citizens speak English less than very well.
    I have seen firsthand the growing diversity in our nation. In my 
district in East Los Angeles and the San Gabriel Valley, more than 60 
percent of my constituents are Latino, and approximately 20 percent of 
individuals are of Asian Pacific Islander descent. Sixty-eight percent 
of families speak a language other than English at home.
    For these communities, culture and language play vital roles in the 
provider and patient relationship. Culture can define how healthcare 
information received, interpreted, and acted upon by patients. 
Communication barriers, such as the lack of langauge services, between 
patients and providers contribute to reduced quality of care, adverse 
health outcomes, and increased racial and ethnic disparities. Such 
barriers can lead to lower patient adherence to medications and 
decreased participation in healthcare decision making. A study by the 
Access Project based at Brandeis University, titled ``What a Difference 
an Interpreter Can Make,'' indicates that more than 25 percent of 
limited English proficient individuals who needed but did not get an 
interpreter reported that they did not understand their medication 
instructions. Non-English speaking patients are also less likely to use 
primary and preventive care and are more likely to seek care in 
emergency rooms.
    Given the existing health inequities of our healthcare system, I 
introduced H.R. 3014, the Health Equity and Accountability Act with the 
support of my TriCaucus colleagues. I am proud that we now have the 
support of more than 100 Members of Congress. In addition, we also have 
a letter of support from more than 300 organizations. I would ask that 
this letter be inserted into the record.
    This legislation, which we introduced in past years, is based on 
many of the Institute of Medicine's recommendations from Unequal 
Treatment: Confronting Racial and Ethnic Disparities in Healthcare. 
This legislation would require Federal agencies to improve access for 
individuals with limited English proficiency and create a Medicare 
demonstration project examining access to care, costs, and health 
outcomes for beneficiaries. Several provisions of H.R.3014 have been 
referred to this Committee and I as stated in a letter addressed to 
Chairman Rangel and Ranking Member McCrery on October 23, 2007, I am 
eager to work with you to enact these provisions.
    Improving access to health insurance, including Medicare, is a key 
part of reducing inequities in health. However, efforts that only 
address access to insurance are inadequate, as evidenced by continuing 
disparities seen within the Medicare population. The Institute of 
Medicare found marked disparities among Medicare beneficiaries, even 
after adjusting for socioeconomic differences. According to the 2007 
National Healthcare Disparities Report, among Medicare patients, 
Latinos and Native Americans are least likely to receive all 
recommended care for heart failure. In addition, an April 2008 article 
published in Health Services Research found that Spanish speakers 
enrolled in Medicare managed care plans have more difficulties with 
provider communication and timeliness of care when compared to non-
Spanish speakers.
    On August 11, 2000, the President signed Executive Order 13166, 
``Improving Access to Services for Persons with Limited English 
Proficiency.'' This Executive Order requires Federal agencies to 
examine the services they provide, identify any need for services to 
LEP individuals, and develop and implement a system to provide those 
services so LEP persons can have meaningful access to them.
    I believe that Medicare, as a leading purchaser of healthcare, has 
the opportunity and responsibility to reduce racial and ethnic health 
disparities. Consequently, I am pleased that some of H.R. 3014's 
provisions were included in H.R. 3162, the Children's Health and 
Medicare Protection Act (CHAMP) of 2007. I and many of my colleagues 
worked hard to pass the CHAMP Act and to protect provisions related to 
the reduction of disparities. Unfortunately, the Senate failed to take 
up the Medicare provisions.
    This past December, before another short-term Medicare physician 
fix bill was enacted, I urged the inclusion of provisions that would 
improve low-income Medicare beneficiaries' access to services. On June 
4, 2008, I also led a letter from the Congressional Hispanic Caucus 
asking for the inclusion of the same provisions in the Medicare package 
recently developed by the Senate Finance Committee. I would like to 
insert this letter into the record.
    I also strongly support a Medicare demonstration protect to improve 
communication between providers and limited English proficient seniors, 
a study on Medicare payments for language services, an Institute of 
Medicine report on the impact of language services on the health of 
Limited English Proficient beneficiaries, and a report on Medicare 
compliance with national standards on Culturally and Linguistically 
Appropriate Services (CLAS).
    The CLAS standards, some of which are mandates for health 
organizations that receive Federal funding, were developed by the U.S. 
Department of Health and Human Services' (HHS) Office of Minority 
Health. They are intended for adoption by healthcare organizations and 
represent a way to improve access to healthcare for minorities, reduce 
inequities, and improve quality of care. I strongly believe that all of 
the CLAS standards should be adopted by Medicare and other health 
organizations. I am pleased that several of these provisions were 
included in S. 3101, the Medicare Improvements for Patients and 
Providers Act, which was recently introduced by Senator Baucus.
    In closing, I would like to take the opportunity to note that our 
health is the product of our social determinants of health, including 
income, race, education, environment and geography. Housing, 
transportation, education, energy, and agricultural policies all impact 
our health, although most Americans think only of our healthcare system 
when we speak about health.
    Our current healthcare system is not the sole reason why racial and 
ethnic populations experience higher rates of death and illness. Given 
this Committee's jurisdiction, I kept my remarks limited to changes to 
our healthcare system. However, it is my hope that this Congress and 
future leaders will consider how seemingly-unrelated policies impact 
our health, particularly the health of vulnerable communities of color.

                                 

    Thank you again for inviting me to testify before you 
today.
    Chairman STARK. And the Honorable Madeleine Bordallo from 
Guam, would you like to proceed?
    Ms. BORDALLO. Good morning again.
    Chairman STARK. Would you pull the microphone right up 
close. Thanks.

  STATEMENT OF THE HON. MADELEINE Z. BORDALLO, A DELEGATE TO 
              CONGRESS FROM THE TERRITORY OF GUAM

    Ms. BORDALLO. Good morning, and thank you, Chairman Stark 
and Ranking Member Camp, for the opportunity to testify on 
behalf of the Congressional Asian Pacific American Caucus.
    Asian and Pacific Islander Americans are one of the 
fastest-growing populations in our country today. Over the last 
18 years, the APIA community has more than doubled from 7 
million to over 15 million individuals.
    A significant number of Americans face challenges on a 
daily basis, but these challenges are unequally borne across 
the spectrum of our ethnically diverse country. Asian and 
Pacific Islander Americans, like Latino Americans and African 
Americans, struggle with overcoming the additional obstacle of 
disparities.
    The sheer diversity in language and culture within the 
greater Asian and Pacific Islander American community presents 
its own challenges. Asian and Pacific Islander Americans 
encompass 49 ethnic groups and over 100 individual and distinct 
languages and cultures.
    The common needs of our minority communities have led to 
the introduction of H.R. 3014, the Health Equity and 
Accountability Act. H.R. 3014, as you will hear today, is the 
product of collaboration between the Congressional Black 
Caucus, the Congressional Hispanic Caucus and the Congressional 
Asian Pacific American Caucus. It is a bill, Mr. Chairman, to 
comprehensively address the pressing issues resulting in and 
contributing today to identified healthcare disparities faced 
by the communities of color all across our country, whether it 
be in Indian country, in border communities, the inner cities 
or in the offshore territories.
    This bill, which has now been introduced in three 
consecutive Congresses, demands this Subcommittee's attention 
and deserves your consideration. Its provisions have been 
scrutinized by the medical, health professional and academic 
communities.
    My colleagues have touched upon different areas of H.R. 
3014 in their testimony this morning. I will address the data 
collection title of the bill.
    Today, there is a serious absence of up-to-date medical 
data on minorities. Because of its diversity, the data gap for 
the APIA community is more glaring and consequential. Right 
now, if you search for diabetes information on the Centers for 
Disease Control and Prevention Web site, for example, you will 
find only data characterized for black, white and Hispanic or 
nonwhite. The fact sheet prepared by the CDC states that 
African Americans, Hispanic/Latino Americans, American Indians 
and some Asian Americans and native Hawaiians or other Pacific 
Islanders are at particularly high risk for type 2 diabetes and 
its complications but that the total prevalence of diabetes, 
both diagnosed and undiagnosed diabetes, is not available for 
Asian Americans or Pacific Islanders. And this, simply put, is 
disturbing and it needs correction.
    Although this one example is drawn from an agency that is 
not under the direct jurisdiction of this Committee, it 
nonetheless aptly illustrates the information gap for 
minorities, particularly for the APIA community. We as a 
Congress simply cannot address or rightly aim to overcome the 
health challenges facing our citizens if we do not even know 
what they are or have some sound measure of the extent of their 
impact.
    Equally disconcerting is the fact that it has now been over 
a decade since the Office of Management and Budget established 
new standards for the collection of Federal data on race and 
ethnic identification, yet their full adoption and 
implementation by certain Federal agencies remains outstanding. 
The Social Security Administration, for example, has made no 
revisions to its Social Security Card application to take into 
account the new standards. The OMB race and ethnic developed 
categories are by no means impossible to implement. Without the 
use of these standards, we are left with inconsistency in 
application; and sound public policy cannot be shaped without 
solid data.
    Our caucus, CAPAC, believes that further disaggregation 
beyond the OMB standards established 10 years ago is warranted 
today to accurately reflect the diversity of the APIA 
community. However, we know this step cannot logically be taken 
or fully pursued into the spirit of the 1997 changes that are 
adhered to by our own Federal Government. Therefore, compliance 
with the 1997 standards and additional collection of data on 
primary language is a priority, both of which are required by 
H.R. 3014 and Subtitle D of the CHAMP Act. So we ask that you 
exercise due oversight to ensure compliance.
    Apart from a compliance with these standards are other data 
collection priorities. Both H.R. 3014 and the CHAMP Act, for 
example, strengthen data collection and analysis by requiring 
that the data be collected from the parent or legal guardian of 
minors and reported to the Centers for Medicare and Medicaid 
Services and other agencies for proper analysis.
    My final point today is to underscore my other colleague's 
statements relative to cultural and linguistic competencies in 
healthcare. This is vital for the APIA community. Roughly a 
third of Asian and Pacific Islander Americans live in 
linguistic isolation. Seventy percent of Cambodians, 68 percent 
of Laotians, 61 percent of Vietnamese, 52 percent of Koreans, 
51 percent of Chinese, 39 percent of Tongans and 22 percent of 
Samoans are classified as limited English proficient. These 
barriers, Mr. Chairman, have severe effects on healthcare 
access, such as patients' ability to understand diagnoses, to 
understand prescription directions. People have and will 
continue to die as a result of misinformation or 
mistranslation.
    It is for these concerns and the others that we urge your 
attention to focus on H.R. 3014. Health disparities for Asian 
and Pacific Islander Americans are very real, and people are 
suffering every day from these disparities.
    I want to thank you, Mr. Chairman, for the opportunity to 
testify on this important issue. We look forward to working 
with you and other Members of the Committee on Ways and Means. 
Thank you.
    Chairman STARK. Thank you for your efforts on this issue. I 
appreciate it.
    [The prepared statement of Ms. Bordallo follows:]
       Prepared Statement of The Honorable Madeleine Z. Bordallo,
                     Delegate to Congress from Guam

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman STARK. Jerry Moran, our colleague from the great 
State of Kansas, would you like to proceed?

STATEMENT OF THE HON. JERRY MORAN, A REPRESENTATIVE IN CONGRESS 
                    FROM THE STATE OF KANSAS

    Mr. MORAN. Mr. Chairman, thank you very much. Thank you and 
Mr. Camp for including me in the invitation today.
    I represent a congressional district that is nearly 60,000 
square miles, 69 counties. The largest community has a 
population of about 45,000 people, what by all standards would 
be considered a very rural district. I think, in regard to 
districts like that across the country, we have a number of 
factors that come together to create significant disparities in 
the availability and affordability of healthcare.
    Age, our population is very senior. Income, we are often--
as rural citizens, our income levels are lower. Distance, the 
ability to travel to access healthcare. Financial, most 
healthcare providers make more money serving patients in a 
wealthier, younger and more urban environment.
    Many of the items that my colleagues have indicated in 
regard to ethnicity and minority issues also are found in many 
rural districts across the country; and for much of the time 
that I have been in Congress, I have co-chaired with my 
colleague from North Dakota, Mr. Pomeroy, the Rural Healthcare 
Coalition, which, incidentally, has many issues in common with 
urban, particularly core center of city, communities across the 
country.
    In addition to that, I have chaired the Healthcare 
Subcommittee in regard to Veterans Affairs in which, for 
example, in my congressional district there is no VA hospital 
and so access even to a government program, the VA, becomes 
very difficult.
    Residents--in fact, I might just highlight some of those 
issues. Residents in rural Kansas have virtually no access to 
public transportation. Therefore, the ability to access 
healthcare before one becomes very sick is limited. Our 
population is very rural, and elderly are likely to have 
chronic diseases and yet 10 to 20 percent less likely to 
receive the recommended pre-screenings, preventative screenings 
or checkups.
    Rural residents tend to be poorer. On the average, per 
capita income in rural areas of the country is more than $7,000 
lower than in urban areas and nearly 24 percent of children in 
rural America live in poverty.
    Higher rates of uninsurance are found in rural communities. 
In the southwest part of my congressional district, which is, 
in many ways, very Hispanic, 16.8 percent of the citizens lack 
healthcare coverage.
    Healthcare professional shortage areas, as defined by the 
Department of Health and Human Services, 25 percent of all 
Kansas counties have a Federal physician shortage area. Of the 
2,157 health professional shortage areas, those are in rural 
areas, as compared to 910 in urban areas.
    It is hard to keep infrastructure in place. Fortunately for 
us in rural America, critical access hospitals have been a 
saving feature for access to healthcare for many across rural 
America. But, having said that, those hospitals face 
difficulties in reimbursement and face a tremendous challenge 
in keeping their doors open.
    Medicare payments to rural hospitals and physicians are 
significantly less than those to their urban counterparts; and, 
in fact, more than 470 rural hospitals have closed in the last 
25 years. Medicare utilization is high in rural districts. In 
fact, Smith County Hospital along my Nebraska border, 8 out of 
every 10 patients admitted to the hospital are Medicare 
beneficiaries.
    EMS is simply we sometimes forget about. And I often find 
myself talking to my constituents about hospitals in 
particular, and I am reminded that many of my counties have no 
hospital at all. The only services that they have immediate 
access to--or at least one hopes immediate access to--is 
emergency medical services, and yet statistics indicate that 
the response time in a rural community is 8 minutes less than 
response time in an urban area. And many, if not most all, of 
our emergency service providers are volunteers. In many 
communities those volunteers are now in their sixties, 
seventies and eighties; and there is virtually no one in their 
twenties and thirties and forties to serve as EMS providers.
    Community pharmacy is something that I hope this Committee 
will consider. Many consequences fell from the Part D 
prescription drug benefit that was provided by Congress. But, 
again, community pharmacy is an important component of 
providing healthcare in rural communities; and yet 7 of my 
counties have no community pharmacy, 32 counties have only one 
pharmacist, and adequate reimbursement for our pharmacies are 
an important component and timely reimbursement as well. 
Nursing home, home healthcare, access to durable medical 
equipment all face significant challenges in rural America.
    And, finally, I would say that it is difficult to recruit 
and retain healthcare professionals, nurses, doctors. At the 
moment, critical shortages of dental providers and almost no 
mental health services are available in most rural communities.
    So as we look at ways that we can try to eliminate 
disparity, I would indicate that, along with the items that my 
colleagues have pointed out related to race and ethnicity, we 
face many of the similar challenges in rural communities across 
the country.
    I thank the chairman and the Ranking Member for inviting me 
to testify, and I would be happy to respond to any questions.
    [The prepared statement of Mr. Moran follows:]
            Prepared Statement of The Honorable Jerry Moran,
         A Representative in Congress from the State of Kansas
I. Disparities in the rural healthcare system
      Rural Kansas residents have greater transportation 
difficulties reaching healthcare providers, often traveling great 
distances to reach a doctor or hospital. There are very few public 
transportation systems and so many folks wait until they are very sick 
before they access the healthcare system.
      Rural Kansans have a higher percentage of elderly likely 
to have chronic diseases like heart disease and diabetes, but they are 
10-20% less likely to receive recommended preventive screenings or 
check-ups.
      In addition, rural residents tend to be poorer. On the 
average, per capita income is $7,417 lower than in urban areas, and 
rural Americans are more likely to live below the poverty level. Nearly 
24% of rural children live in poverty.
      Higher rates of uninsurance are also found among rural 
communities. In 2001, the Southwestern region of Kansas had the highest 
proportion of uninsured at 16.8%. It is also in these rural regions 
where we find higher rates of delayed entry or too few prenatal care 
check-ups for pregnant women. Rural residents strain the capacity of 
rural hospitals when hospital emergency rooms are used inappropriately 
as a substitute for a medical home.
      There are 2,157 Health Professional Shortage Areas 
(HPSA's) in rural and frontier areas of all states and U.S. territories 
compared to 910 in urban areas. 25% of all Kansas counties have federal 
physician shortage area designation for primary medical and all of 
there are rural counties.
II. It is hard to keep the Healthcare infrastructure in place
      Having access to a local hospital and their services is 
important



There are 75 hospitals in the First District of Kansas, many of them being 
Critical Access Hospitals (25 beds or less). They allow people the ability 
to access local care when they are sick and are the cornerstone to the 
rural healthcare delivery system.



One challenge to keeping the doors open is that there is less volume than 
in many urban settings. In addition, Medicare payments to rural hospitals 
and physicians are dramatically less than those to their urban counterparts 
for equivalent services. This correlates closely with the fact that more 
than 470 rural hospitals have closed in the past 25 years.



Many rural hospitals have higher Medicare utilization rates than their 
urban counterparts. In my district, Smith County Hospital, over 8 out of 
every 10 hospital admissions were from Medicare beneficiaries.

      EMS providers face big challenges. There are higher rates 
of death and serious injury accidents in rural versus urban areas. One 
reason for this is that in rural areas, prolonged delays can occur 
between a crash, the call for EMS, and the arrival of an EMS provider. 
Many of these delays are related to increased travel distances in rural 
areas and personnel distribution across the response area.



National average response times from motor vehicle accident to EMS arrival 
in rural areas was 18 minutes, or eight minutes greater than in urban 
areas.

      Keeping the additional healthcare services and players in 
business is important as well.



Community Pharmacies are on the front lines of the healthcare delivery 
service. Currently, there are 7 counties in Kansas that have no drug store 
and 32 counties have only one available.



It is important that we are adequately reimbursing pharmacies for the 
Medicaid prescriptions that they are filling and it is important that we 
pass legislation to ensure that they are reimbursed in a timely manner.



Nursing homes, Home Healthcare and access to durable medical equipment is 
also very important to rural residents.

III. It is difficult to recruit Healthcare Personnel
     It is extremely difficult to recruit healthcare 
professionals to places where doctors are few and access to major 
metropolitan hospitals requires hours of travel. According to the U.S. 
Department of Health and Human Services, while a quarter of the 
population lives in rural areas, only 10 percent of physicians practice 
there.



Kansas has 234 physicians specializing in the specialty of obstetrics. Only 
59 have practices located outside the large urban counties and in fact, 
only 21 are available in the entire western \1/2\ of the state.



One lifesaving program has been the J-1 Visa Waiver program. The J-1 Visa 
Waiver program provides opportunities for graduates of foreign medical 
schools, who have trained in U.S. medical residency programs on the J-1 
cultural exchange visa, to stay in the United States if they serve for 
three years in an area that has a health professional shortage. These 
designated health professional shortage areas can occur in rural areas as 
well as urban areas.



Kansas has been able to recruit 98 physicians to work in underserved areas 
and with underserved populations since 2002 through the J-1 Visa Waiver 
program.

      Additionally, the lack of mental health and dental 
services continues to be a significant problem in most counties in 
Kansas. The 2005 Health Professional Underserved Areas Report shows 
that only nine counties in Kansas have adequate numbers of mental 
health professionals (1 psychiatrist for 30,000 population) and only 
twenty counties have adequate numbers of dental professionals (1 
dentist for 5,000).
      Anywhere from 57 to 90 percent of first responders in 
rural areas are volunteers

                                 

    Chairman STARK. Well, I thank all of our colleagues for 
joining us.
    Dr. Christensen, it was a year ago I think you testified 
before us on the end stage renal disease issue, and we agreed 
then that any changes in the dialysis reimbursement must not be 
a one-size-fits-all. And we think this last bill had the 
requisite flexibility to respond to individual patient needs.
    Modernizing that system is even more critical today because 
of the perverse incentives of the current system which has 
encouraged unusual dosing of Epogen and has put many patients' 
health at risk. So I hope we will work together on this issue, 
and I hope that the Senate puts the patient needs ahead of 
industry profits. I think we will have some time to review that 
again.
    Congresswoman Solis, you brought up an issue on disparities 
that--and I think several of you have touched on this--that it 
is just not a coverage issue. It goes to access, that we find 
disparities among the Medicare population, which is a uniform 
coverage. Even if you adjust for social economic status, we 
could use your community as an example. Do you want to just 
expand on why addressing disparities transcends access and 
insurance and the other moves that we might make to correct 
that?
    Ms. SOLIS. Well, I think one of the issues is that our 
healthcare system for many, many years has looked typically at 
majority population in terms of how that service delivery is 
provided. Just recently, you see some innovative, you know, 
footnotes by, for example, researchers through the Kaiser 
Foundation who realized that you can actually save a lot more 
money if you start to tailor the services to better fit and 
better suit the population at hand; and what we are finding is 
that we do have to do much more in providing incentives for our 
university medical schools, for example, to recruit and retain 
individuals from rural America, from inner city America who are 
reflective of the populations that are faced with these chronic 
illnesses. I think it says a lot when you do bring people who 
are much more familiar with individuals that they would serve, 
that there is much more ability to be able to break down those 
barriers of communication, understand culturally the 
differences that are unique to different populations.
    I think that my colleague, Ms. Bordallo, evidently gave us 
some very good facts in terms of even the differences in the 
API community, Tagalog, Filipino, Mandarin, all the various 
different groups that need to have a different perhaps 
interpreter or type of service that is available to them.
    I know that we have been reluctant in the last few years in 
the Office of Civil Rights to actually push for better outcomes 
in terms of what our healthcare hospitals and our centers are 
providing. I don't think that is a negative. I think that that 
is something that we should continue to work toward.
    Mrs. Christensen. Chairman Stark, may I add?
    Chairman STARK. Sure.
    Mrs. Christensen. I just wanted to again call your 
attention to the IOM report on equal treatment of a few years 
ago, and the hundreds of articles that were reported on there 
and have been reported since that also point to discrimination 
within the healthcare system. So that individuals who have full 
insurance and present themselves either private or public 
within that system, everything else being equal except for race 
and maybe language, did not receive the same kind of diagnostic 
evaluation or if that diagnostic evaluation is done are not 
offered the same level of treatment and care.
    Chairman STARK. I don't think you would find anybody who 
would disagree with that. And I think what we have to look 
forward or look for with all of your help is, from our 
standpoint, what can the Federal Government do, not what Blue 
Cross or Aetna or the private plans, over whom we have little 
jurisdiction. But what can we do as a Federal Ggovernment to 
change that.
    And, Congresswoman Bordallo, you talked about better data. 
And it has been--what--11, 12 years since OMB published their 
standards for the collection of data; and we are still not 
doing it. Do you think that it is urgent and that we can do it 
without getting into discrimination questions, collect more 
data in our Social Security system so that we at least can 
begin to look at the numbers and see what is happening? Do you 
support that?
    Ms. BORDALLO. Yes. Yes, Mr. Chairman, in answer to your 
question. Because I represent the Asian Pacific area, which is 
the fastest-growing; and we have so many different ethnic 
groups, 49, perhaps more. And, yes, I would say that this would 
be a priority, to gather the data before we can even have any 
understanding of what the situation is or how many people are 
affected.
    Chairman STARK. Thank you.
    Jerry, you are an outlier as far as topics go, because I 
really hadn't anticipated dealing with the rural issue. But it 
is one that this Committee, to my knowledge, in 20, 25 years 
has dealt with the issue in two ways. One, we have always known 
as a political fact of life that whatever we do to aid rural 
America through the Medicare system will be doubled or tripled 
on the Senate side when it gets there; and we have to resolve 
it in conference. And so we have always accepted that and 
always look forward to our colleagues in the other body 
correcting whatever inadequacies we might provide.
    But let me point out a couple of things and let you comment 
on them.
    You did mention, you know, 470 rural hospitals have closed 
in the past 25 years. That is my tenure both in the minority 
and majority on this Committee. But if you look at it, that is 
less than 15 hospitals a year, and we have never had a year 
when 20 hospitals have closed. So maybe three-quarters of them 
are rural. Out of 6,000 hospitals, that ain't bad. And we 
usually figure, as I have always said, that most of the cause 
of closing rural hospitals is because the doctor died or moved 
out of town.
    And what I would like to think as times change and Mr. 
Pomeroy comes--I don't think he has any big towns in his State. 
But, I mean, you haven't seen little cities until you have gone 
to North Dakota.
    But what I have noticed is that the clinics begin to take 
on more procedures and that transportation may be a solution. 
Because a 10- or 20-bed hospital just can't support the kind of 
care that you want when you are faced with a cancer or a 
cardiac problem. You are going to drive the 100 or 200 miles or 
get flown in a helicopter. And I think that is what you and I 
would want.
    So my sense is that how--and I don't know whether you would 
agree with this. Politically, it is impossible to stand by and 
watch a hospital close on your watch. We recognize that.
    We wrote in this Committee the peach and each act, which 
more or less said here is how a 10-bed hospital can get off-
stage with the local politicians. We will make it a long-term 
care facility or an outreach facility somehow, quite frankly, 
to give political cover to people who may have to encourage 
their residents to take a longer trip to get them more 
sophisticated medical care, data, electronic data, if we had 
that more broadly, so it was available, teleconferencing, all 
of those things.
    And I would hope that, if you don't find that offensive, 
that you would continue to support whatever efforts we can make 
to kind of modernize, if you will, the rural system and--
because I do agree that we can help with the visa issue, and I 
think that that will help us with diversity. And I have no 
objection to that. So I hope that you will continue to be 
involved in this issue, because I would hate to see Mr. Pomeroy 
have to carry the whole ball all by himself.
    Thanks for your testimony.
    Any comment?
    Mr. MORAN. As much as I admire and respect Mr. Pomeroy, I 
would like to say that he and I work closely together, and I 
have been to some of his communities. In fact, we took----
    Chairman STARK. I am not sure you both voted the same way 
on the agriculture bill this year.
    Mr. MORAN. We did not vote the same way on the ag bill or, 
more surprising, nor did we vote the same way on the 
prescription drug benefit.
    But Mr. Pomeroy and I had the CMS administrator in my 
district and his State several years ago, Mr. Skully. And, 
incidentally, it was an interesting experience in my mind to 
listen to Mr. Skully see for the first time a critical access 
hospital. Here is the person who is in charge of the CMS 
program responsible for Medicare and Medicaid services and yet 
had not at that time ever seen a critical access hospital. His 
reaction was very foretelling to me, which was, Congressman, 
they deliver great quality healthcare here, don't they, but 
there are no frills, are there?
    And, to your point, I think that is what we are 
anticipating. And it is the way we live our lives in much of 
rural America, is there are no frills. That is what our 
critical access, our small, less-than-25-bed hospitals provide, 
is basic services; and our ability to attract other healthcare 
professionals I think is dependent upon having that hospital 
there.
    So while Mr. Pomeroy and I are very active in renewal of 
the J-1 visa, the Conrad 30 program, our ability to utilize the 
program--and I appreciate what my colleague said about 
attracting physicians into medical schools who have diverse 
backgrounds, in our case, a rural background. We have 
discovered that the best shot we have at getting a doctor to a 
rural community in Kansas is that they grew up in a rural 
community in Kansas or someplace. But what we discover is they 
go off to medical school, and they marry someone who likes 
restaurants and shopping, and even the hunting and fishing that 
we have becomes less appealing when the spouse has different 
ideas.
    So the point I would perhaps differ with you, Mr. Chairman, 
on is that those--particularly those critical access hospitals, 
yes, they are not there to provide every service imaginable; 
and we need regional medical centers and specialized hospitals 
in which a transportation system will allow rural residents, 
patients to be transported to receive that kind of care. But 
for the very basics, including just emergency room coverage and 
our ability to keep physicians and other healthcare providers 
in communities, those small hospitals are critical.
    Chairman STARK. Thank you very much.
    Mr. Camp, would you like inquire?
    Mr. CAMP. Thank you, Mr. Chairman.
    Thank you all for testifying.
    Dr. Christensen, thank you for your leadership on end stage 
renal disease and dialysis.
    I am interested in, Congresswoman Solis, your comment about 
a demonstration project to improve communication between 
providers and limited English proficient seniors. Is CMS doing 
any of that, are you aware, currently?
    Ms. SOLIS. From what I have learned, there hasn't really 
been an adequate growth in terms of funding these kinds of 
efforts. I think maybe in the last 2 or 3 years you have seen 
some movement but not enough where we can actually even enforce 
the current codes in the law that say that we are required to 
provide better access services to those patients that have 
cultural linguistic, linguistic barriers. So I think that we 
still have a ways to go, and I would hope we could work with 
you and the Committee to see that we get support for that.
    Mr. CAMP. All right. Thank you.
    And, Congresswoman Bordallo, you mentioned a data gap; and 
we have seen that in all areas. We just had a hearing the other 
day on HSAs, and we are using data from the first year the 
program was enacted to try to draw our conclusions about where 
HSAs are today, even though much of the growth occurred well 
after the first year of implementation.
    So there is a real data gap. There is a lag in health data 
all across the spectrum. I think we have difficulties in 
getting access to the right kinds of information. So I think 
that is something that we need to really work on particularly, 
and we are almost in 2009, making decisions for 2009 and 2010. 
To not know even the last couple of years is a very difficult 
thing.
    Mr. Moran, you mentioned many of the disparities between 
rural and urban areas. One of the things I didn't hear you 
mention was the disparities in reimbursement; and we have long 
talked about this in this Committee about the difference 
between many of the large urban areas like Miami, for example, 
and just about anywhere else in the country in terms of the 
reimbursement rates.
    Do you think that is a factor in some of the disparate 
health services and treatment available to rural Americans?
    Mr. MORAN. Absolutely, Mr. Camp. A question that you know 
the answer to and that you and I agree totally on it.
    In regard to our ability to attract and retain 
professionals, reimbursement is a significant component of that 
inability. If you are a physician that wants to make more 
money, you will choose to live in an area in which your 
Medicare and Medicaid components of your practice are less than 
most rural areas of the country.
    Reimbursement of hospitals. Even the cost-based 
reimbursement that occurs in regard to a critical access 
hospital is not true of cost-based reimbursement.
    And I remember my first year in Congress, 1997, we had the 
Balanced Budget Act. One of its premises was that we could 
reduce the amount of reimbursement for Medicare providers in an 
effort to balance the budget. Noble goal of balancing the 
budget. But when 80, 90 percent of your patient load are 
Medicare patients in a hospital, you have no place to turn, 
with perhaps the exception of raising property taxes to keep 
your hospital doors open.
    So in each of these instances, the reimbursement rate, the 
disparity between rural and urban, the geographic factor that 
occurs in the physician reimbursement, there is an actual 
geographic component of the reimbursement a physician receives 
under the belief that it is less expensive to live and practice 
medicine in a rural community. I don't know that the facts 
would bear that premise out.
    Mr. CAMP. All right. Thank you all very much.
    Thank you, Mr. Chairman.
    Chairman STARK. Thank you.
    Mr. Doggett, would you like to inquire?
    Mr. DOGGETT. Thank you, Mr. Chairman; and thanks to each of 
our witnesses. Congresswoman Solis, could you expand on the 
role that you believe Medicare can play in addressing the 
disparities that you have described?
    Ms. SOLIS. Well, I think one of the issues that--actually, 
there are several items that I would touch on. And one is, of 
course, the lack of adequate healthcare professionals that are 
coming into the healthcare system, number one. We do have a 
shortage in our labor force there, and we have to really 
incentivize our teaching hospitals to identify individuals and 
even those that come from different countries who are qualified 
in giving them the ability to come and work here. I think that 
that is one way of addressing it.
    I think also providing incentives so that people will work 
in rural, low-income or underserved communities. We face the 
same problems that rural America does when you see a low 
reimbursement rate. You see doctors in East Los Angeles and I 
am sure in the State of Texas where you find Latino doctors who 
will now refuse to take on any more Medicare/Medicaid patients 
because of the lack of low reimbursement. Even for those 
professional doctors that specialize in special treatment, 
orthopedic surgeons, we are also finding hip replacement, those 
kinds of things that we see occurring much more in our 
community, individuals are very far and few, maybe 1 to 10,000 
a population, one specialty doctor for a population of 10,000. 
That is wrong.
    We need to do more also to make sure that we fully utilize 
those public clinics. In our districts, for example, in Los 
Angeles we don't have access to many of those bigger hospitals, 
community hospitals. Much in our county have been closed down. 
So we rely very heavily on the public hospital community 
centers there that provide assistance.
    But to really do more--how can I say--extensive outreach to 
help identify treatment opportunities and prevention and 
education and to make sure that we have lay people that are 
fully trained this can provide that assistance in an atmosphere 
that is well received and that people will feel trustful of----
    You know, there is a big issue now in our community with 
this whole immigration debate and why people sometimes won't 
even access healthcare because of fear that they may be somehow 
detained or denied healthcare when in fact they are eligible 
for this aid.
    So I think that we have a long way to go; and there is 
multiple, multiple things that we can do, including beefing up 
our research institutions to do more specialized review in 
terms of why it is that there is a higher propensity of Latinas 
to have breast cancer, why it is we see an increasing number of 
teenage pregnancy amongst Latinas, what are the cohorts in our 
community so that we can provide prevention so that at the end 
of the day we don't end up having to pay for this accumulation 
of costs at our emergency hospital or trauma unit when the 
services could have been provided maybe, you know, a year ago 
in a more comfortable, informative manner. So there is many, 
many things that we can do.
    I know that this Committee is very, very strongly 
supportive of some of the reforms we are talking about; and I 
would hope that we can challenge our Presidential candidates to 
adopt the discussions that we are having here today, because I 
really think this is the most burning issue of our time.
    Mr. DOGGETT. One of the things that is at the top of the 
list is to see that our healthcare professionals reflect the 
population as a whole and that we have, especially in the 
medical specialties, a more diverse workforce that is aware and 
sensitive to these problems.
    You made mention also to the term promotoras. I have met 
with some of the young women in south Texas that do that work, 
some of the very problems that you were referring to, breast 
cancer, teenage pregnancy. How would you use them and what--it 
is a demonstration project you referred to under CHAMP one 
might use them. What role would they play in this process?

RPTS HUGILL

DCMN MAGMER

    Ms. SOLIS. Well, they would be kind of the first 
responders, so to speak, out in the community that have a 
better map or design of what is taking place in their 
community, in their neighborhood; and they are trained 
individuals that typically will meet with the core group of 
families--typically in this case they may be females--and 
they'll talk about--and it's not just for one gender. They'll 
talk about how to go about prevention, what signs to look for 
for any diseases. There's a higher rate of asthma in the 
community. They can talk about what needs to be done to care 
for the family, the child, but also to help enlist these 
individuals on knowing what services are currently available so 
we don't duplicate our efforts but we are more strategic also 
in a figure which program they can conceivably apply for. And I 
think that's our biggest test right now, that people get so 
overwhelmed with paperwork and not understanding which program 
fits their particular need.
    So individuals in the promotoras program and even in the 
State of California where there are 1,200 promotoras right now 
and they're not all publicly funded, those efforts have shown 
very, very positive outcomes in terms of decreasing the amount 
of money that we could provide in terms of prevention and at 
the end of the day have more money to do more outreach and 
enrollment in some of these very important programs like the 
SCHIP program that are very helpful in our communities, 
especially in the State of Texas.
    Mr. DOGGETT. Thank you.
    Thank you, Mr. Chairman.
    Chairman STARK. Mr. Thompson, would you like to inquire?
    Mr. Pomeroy, would you like to inquire?
    Mr. POMEROY. I would, Mr. Chairman.
    First of all, I would like to commend this most superb 
panel. I think we are all used to member panels, and they put 
in their kind of constituent-provided or interest-provided 
talking points, and that is about the end of it. It is clear 
that each of the panel members has demonstrated a lot of 
knowledge that I would say is approaching policy expertise in 
these areas, and I really do commend them.
    It has been my pleasure to serve with Mr. Moran as co-Chair 
of the Rural Healthcare Coalition, and I look forward to 
continuing working with him on rural issues. I think that he 
has advanced a number of issues that I completely agree with 
his take on them.
    I want to, rather than ask questions of the panel, put into 
the record, Mr. Chairman, a group that is largely rural based 
but presents health disparities toward a minority population as 
profound, I believe, as any and that is the Native American and 
Alaska Native populations. The American Indian and Alaska 
Natives born today have a life expectancy of 2.4 years less 
than the general population. We have decreased the infant 
mortality rate with Native American children 64 percent during 
the years '72 to '99, and that's a tremendous achievement, but 
they still die at a rate of 10 per 1,000, which is 24 percent 
higher than other populations.
    Of all of the disparity indices relative to Native 
Americans, to me the most stunning is mortality rates for 
specific causes compared to general population. Tuberculosis, 
Native Americans die at a 500 percent greater rate. Alcoholism, 
638 percent greater rate. Diabetes mellitus impacting Native 
American mortality, in other words, the death rate for Indians 
dying of diabetes, 291 percent greater than the normal 
population. Unintentional injuries, 215 percent. Pneumonia and 
flu, 67 percent higher mortality. Gastrointestinal, 38 to 40 
percent. Heart disease, 20 percent.
    One of the more humiliating moments in my congressional 
service came when I went to an Indian reservation to talk about 
the great news of providing diabetes testing strips under 
Medicare. Having made my little presentation, I asked, by the 
way, what is the longevity rate here on the reservation? For 
males, it was 63 years. They were dying 2 years on average 
before they became even Medicare eligible. We see 73 percent of 
American Indians and Alaska Natives residing in health 
professional shortage areas, 90 doctors per 100,000 compared to 
229 per 100,000 across the general population.
    Mr. Chairman, I would like to submit in the record my 
statement as well as two documents, Indian Health Service Facts 
on Indian Health Disparities and a document prepared by the 
Center for Rural Health in North Dakota on health disparities. 
I did not want to take panel time. I think it's important for 
this Committee to hear from other Members not on the Committee, 
but I do want this in the record on health disparities.
    Chairman STARK. Without objection.
    [The information follows:]
    ******** COMMITTEE INSERT ********
    Mr. POMEROY. Thank you; and I yield back, Mr. Chairman.
    Chairman STARK. Mr. Becerra, would you like to inquire?
    Mr. BECERRA. Thank you, Mr. Chairman, and double thank you 
for holding this hearing. Many of us have believed that for 
many years we should have had an opportunity to discuss this 
issue further, and I want to thank you very much for your 
interest and your commitment to having this issue raised and 
hopefully addressed in the near future.
    To our panelists, thank you very much for your testimony. I 
think each and every one of you point out the reason why we 
need to move on this for any number of reasons. Whether it's 
race, ethnicity, geography, we have to take all those things 
into account.
    And a special thanks to Congresswoman Solis for her active 
involvement not only in the Congressional Hispanic Caucus but 
back in California on the issues of healthcare over the years.
    To me, I find something very stunning, and one of our 
witnesses, Dr. Michael Rodriguez, will I suspect testify to 
this a little later on, but three-quarters of physicians, when 
they are treating people who are limited in their English 
understanding, three-quarters of family physicians use family 
members to do interpretation, translation. Now I have got to 
tell you that maybe if you want directions on how to get to the 
monument a few miles away or how to get to the cinema to go see 
a great movie it's okay to have your family member translate 
for you. But when it's the issue of what medication you should 
take or whether you should have an amputation, having a family 
member doing the translation services for you I think is one of 
the biggest mistakes we make with regard to healthcare.
    And when you take into account that the Civil Rights Act--
Title VI of the Civil Rights Act actually mandates that 
healthcare providers that are receiving Federal funds provide 
meaningful access to all of their programs and activities to 
people who have limited English proficiency, you wonder what's 
going on. The Civil Rights Act says you are required to provide 
these services if you are taking Federal dollars. Yet, at the 
same time, you have a Medicare Program that doesn't reimburse 
providers to try to provide these interpretation services.
    Dr. Rodriguez will probably testify on these. It's in his 
written testimony that the average cost to provide these 
interpretation services, competent interpretation services, 
professional interpretation services would probably add about 
$4 to a medical visit, 4 bucks to save an amputated leg or to 
make sure you are taking about your prescription medication 
correctly.
    And perhaps more to the point and the reason why I think 
this hearing, Mr. Chairman, is so important is that the issue 
of trust for a lot of these patients who, whether it is because 
they are low income or a racial or ethnic minority or language 
challenged, don't receive the best medical assistance. 
Sometimes they leave the hospital with less than a good 
experience.
    The problem with that in my encounters and my experience 
shows me is that that means you have people who are less 
confident in their medical providers and those professionals 
that are telling them what to do with their lives and their 
health. And if you are less willing to accept the word of a 
physician because you didn't have a good outcome or a good 
encounter, there is a very good chance that you are not going 
to trust what that physician is telling you when it comes to 
some perhaps lifesaving treatment or service. And so to 
undermine the trust that we would have between the provider, 
the doctor, and the patient to me is perhaps one of the 
greatest sins that we commit in allowing disparities to occur; 
and so I think it is critical that we begin to address this 
issue. And I want to thank my colleagues for their excellent 
testimony in bringing to light the different disparities and 
the types of solutions that we can devise to try to address 
this.
    And with that, Mr. Chairman, I will yield back the balance 
of my time.
    Chairman STARK. Thank you.
    Mrs. Tubbs-Jones, would you like to inquire?
    Mrs. JONES. Thank you, Mr. Chairman.
    I want to thank all of my colleagues for appearing. 
Unfortunately, it seems like I end up at the end of the list, 
and I am not saying I was discriminated against. I am just 
saying I am at the end of the list, and all the people I want 
to ask questions of, unfortunately, had to leave. So I am going 
to ask my question and answer my question.
    Chairman STARK. It is difficult for me to understand how a 
person so young could have risen to such seniority on this 
Committee.
    Mrs. JONES. I know. It is because of the way the process 
operates. I won't talk about that about that now.
    I'm joking.
    All kidding aside, Mr. Moran, my colleague, your discussion 
has specifically been focused on urban and rural disparities. 
Can you shed any light on the disparities that occur in your 
congressional district as a result of race?
    Mr. MORAN. Yes, in the sense that I represent a very 
Hispanic district, at least in comparison to other 
congressional districts in the Midwest, and what I would point 
out is the importance of community health clinics in meeting 
the needs not only of individuals with low incomes but 
particularly individuals with low incomes in the minority 
population.
    In southwest Kansas, where the largest proportion of 
Hispanics reside, United Methodist Ministries is a community 
healthcare provider that provides medical services to that 
community. It is significant, it is important, and even in 
rural America somewhat contrary to the stereotype. Our 
population is very diverse.
    Mrs. JONES. What percentage Hispanic is it?
    Mr. MORAN. Eleven percent Hispanic.
    Mrs. JONES. Your congressional district.
    Mr. MORAN. Yes.
    Mrs. JONES. And what is your district again?
    Mr. MORAN. It is the First District of Kansas, which is 
every community in Kansas that you have never heard of.
    Mrs. JONES. You don't know that.
    Mr. MORAN. I don't know that.
    Mrs. JONES. There you go.
    Mr. MORAN. I am stereotyping in this case. But it is 
everything except Wichita, Kansas City, and Topeka.
    Mrs. JONES. Okay. Thanks a lot.
    I would have focused much of my questions to my colleague, 
Donna Christensen, because it is my job as the African American 
Member of this Committee to focus on issues that focus around 
the African American community, and I want to quickly just read 
kind of questions and answers that I would have asked Dr. 
Christensen were she still here.
    One of those was the source of growth in stage renal 
disease in racial and ethnic minority communities; and it 
includes a spike in conditions such as diabetes, hypertension 
and a variety of socioeconomic factors. It can also be 
attributed to a lack of access to care and lack of coverage. 
Effective programs or tools or strategies to reduce the 
disproportionate number or burden of ESRD, or end-stage renal 
disease, in these communities can include access to care and 
health insurance coverage, education about diabetes and 
hypertension prevention, national policies that recognize the 
diverse needs of the end-stage renal disease population.
    And one of the reasons I focus on this is because of the 
disproportionate number of people in my own community that I 
have seen have amputations as a result of end-stage renal 
disease. And to see a person lose limbs in the course as a 
result of that disease is devastating and to know that there 
are opportunities within our healthcare community to reduce 
some of that are significant.
    I had an opportunity just the other day to speak with a 
physician who specializes in vascular surgery to attempt to 
reduce the number of amputations that occur in that community. 
I would have had a conversation with Dr. Christensen around 
efforts to address the issue of overprescription of Epogen and 
how do we address that and how we are looking at bundling and 
what impact that has on our community. And the reason we focus 
on that is because we don't want people to have the perception 
that physicians are overprescribing, but, on the other hand, we 
don't want to say we don't want to be involved in legislating a 
medical practice. That should be left to physicians and 
prescribers of prescriptions.
    I do want to focus in on for a moment a recent American 
Journal of Kidney Disease report dated April, 2008, that 
indicates that when the travel time for dialysis increases from 
1 to 15 minutes to 15 to 60 minutes, mortality increases by 20 
percent.
    Additionally, if you look in areas with high numbers of 
smaller facilities, they also happen to be areas in which high 
proportions of African Americans are treated. If these 
facilities are closed because of a flawed payment system, 
African Americans with ESRD would face greater travel times to 
other dialysis facilities and thus would face greater risk for 
mortality.
    I see I am out of time; and again I want to thank my Chair 
for hosting this Committee around healthcare disparities, 
racial and ethnic healthcare disparities. You can see that it 
is a topic that deserves much more time and much more 
attention. But we have an opportunity to address additional 
things such as cultural problems within the healthcare delivery 
service, access, and on and on and on.
    I thank you, Mr. Chairman, for the opportunity to present 
in this area. I want to again thank my colleagues for taking 
the time to come before the Committee, and I look forward to 
the second panel where we will have a further opportunity to 
address some of these issues.
    Chairman STARK. I thank you all, those that have been able 
to stay. I know that Congresswoman Christensen had a 
Subcommittee to Chair, and Ms. Bordallo had other appointments. 
So I appreciate your taking the time and patience to be with us 
this morning. Thanks very much.
    Mr. MORAN. Thank you, Mr. Chairman, for allowing this 
outlier.
    Ms. SOLIS. Thank you, Mr. Chairman.
    Chairman STARK. I would like to ask our second panel to 
come on up to the witness table. And I won't go through each 
biography in the interest of time, but many of our witnesses 
have come from around the country, and they have considerable 
experience and expertise.
    But I have to especially welcome Dr. Anthony Iton, who 
comes from my district in Alameda, California. He is the 
Alameda County Health Officer and has devoted his career to 
working on these issues before us today.
    Just to give you a sense of Dr. Iton's qualifications, he 
has a medical degree from Johns Hopkins. He's board certified 
in internal medicine and preventative health. He has a law 
degree and a master's in public health from the University of 
California at Berkley. He is a member of the California Bar. 
And we just feel fortunate having him serve my constituents.
    And I want to, as I say, welcome the other witnesses, all 
of who have outstanding credentials. They just aren't lucky 
enough to live in the 13th Congressional District of 
California.
    And I am going to call on you as best I can read your names 
from here. We have, as best I can pronounce these--I am going 
to just through the list--Dr. Lillie-Blanton, Dr. Akhter, Dr. 
Jang, Dr. Iton we know, Dr. Satel, and Dr. Rodriguez.
    Chairman STARK. Dr. Lillie-Blanton, would you like to lead 
off?

STATEMENT OF MARSHA LILLIE-BLANTON, DR.P.H., SENIOR ADVISOR ON 
    RACE, ETHNICITY AND HEALTHCARE, KAISER FAMILY FOUNDATION

    Ms. LILLIE-BLANTON. Thank you, Mr. Chairman and Members of 
the Subcommittee on Health, for the opportunity to testimony on 
the issue of racial disparities in health and in healthcare.
    I am Marsh Lillie-Blanton, Senior Advisor on Race, 
Ethnicity and Healthcare at the Kaiser Family Foundation and 
also an associate research professor in the George Washington 
University School of Public Health and Health Services.
    In the past half century, the United States has made 
remarkable progress in improving the health of all Americans, 
including Americans of color. We also have seen tremendous 
gains in access to medical care since the mid-1960s. Medicaid 
and Medicare, along with the enforcement of the 1964 Civil 
Rights Act, deserve much of the credit for improved access. Yet 
disparities in health persist and our health system provides 
inadequate care for some and excludes millions of others.
    My testimony today focuses on the role of health insurance 
in reducing disparities in healthcare and in health status, two 
distinct but related challenges. Although the causes of health 
disparities are complex and result from multiple interrelated 
factors, differentials in access and in quality contribute to 
these disparities.
    The landmark IOM report, Unequal Treatment, provided 
compelling evidence that racial disparities in care persist. 
The extent to which medical care contributes to health outcomes 
may be relatively small when the outcome is defined as overall 
population mortality. However, the effects of medical care are 
immeasurable for individuals with specific health problems such 
as asthma or heart disease or who may need the guidance from 
the health system to help change personal behaviors.
    However, addressing healthcare disparities is important for 
reasons far beyond their impact on health outcomes. The racial 
divides in the U.S., whether in education, employment, or 
healthcare, reflect the Achilles heel of this Nation. Healing 
the wounds that separate this Nation is important if we are to 
move forward as one Nation.
    The U.S. was founded on ideals of equality of opportunity, 
and continuing efforts to realize those goals are warranted 
throughout all sectors of society. In the health system, 
assuring that individuals with similar healthcare needs are 
similarly treated is a basic matter of fairness.
    Health insurance coverage provides the final means to 
access care in the U.S. Of the 47 million non-elderly Americans 
uninsured in 2006, approximately half, 24 million, are people 
of color. While younger adults are more likely than older 
adults to be uninsured, older adults, especially the nearly 
elderly, are a particularly vulnerable group because health 
problems increase with age.
    The consequences of being uninsured can be serious. When 
compared with the insured, the uninsured are less likely to 
have a regular doctor and are more likely to be hospitalized 
for preventable conditions. Uninsured adults across racial 
ethnic groups are at least twice as likely as the insured to go 
without a doctor visit in the past year.
    A recently completed study panel of the National Academy of 
Social Insurance concluded that racial disparities exist not 
only among the privately insured but also among Medicare 
beneficiaries in fee-for-service and managed care. One study 
cited in the report analyzed HEDIS measures for beneficiaries 
enrolled in Medicare managed plans. The study found that the 
white/black gap narrowed for seven of the nine HEDIS measures 
but was not eliminated in any category, and it widened for two 
measures.
    One of the most important tools for tracking disparities in 
access and quality of care is the annual National Healthcare 
Disparities Report. The 2007 report found that there was either 
no change or a worsening of disparities in quality on more than 
half of the 16 indicators tracked over time across all racial 
ethnic groups. In other words, healthcare disparities in the 
last 5 years are not getting any smaller.
    Race and ethnicity clearly matters in our healthcare 
system, but so do other many other factors such as the 
geographic availability of health services or the language 
capability of the providers. The wealth of evidence, however, 
that insurance makes a difference in opening the door to the 
health system suggests that reducing the number of uninsured 
would be one effective step in reducing racial and ethnic 
disparities in care.
    Racial disparities among persons who are insured, however, 
are an indication that expansions in coverage, though 
necessary, are not sufficient. Efforts therefore are needed to 
increase the knowledge base of what works and then apply that 
knowledge to help close the gap in the quality of care.
    I appreciate the opportunity to testify before the 
Committee today and welcome your questions. Thank you.
    Chairman STARK. Thank you.
    [The prepared statement of Ms. Lillie-Blanton follows:]
  Prepared Statement of Marsha Lillie-Blanton, DrPH, Senior Advisor on
        Race, Ethnicity and Healthcare, Kaiser Family Foundation
    Mr. Chairman and Members of the Subcommittee on Health, thank you 
for the opportunity to testify on the issue of racial disparities in 
health and healthcare. I am Marsha Lillie-Blanton, Senior Advisor on 
Race, Ethnicity, and Healthcare at the Kaiser Family Foundation, and 
also an Associate Research Professor in the George Washington 
University School of Public Health and Health Services.
    Today, 1 in 3 Americans self-identify as either Hispanic/Latino, 
African American/Black, American Indian/Alaska Native, Asian American, 
or Native Hawaiian or Pacific Islander. By 2050, half of the U.S. 
population will be a person of color (Figure 1). This demographic shift 
in the population suggests that there are economic as well as health 
consequences of our failure to eliminate longstanding disparities in 
health status and in access to healthcare.
    In the past half century, the United States has made remarkable 
progress in improving the health of all Americans, including Americans 
of color. We also have seen tremendous gains in access to medical care 
since the mid-1960s. Medicaid and Medicare, along with the enforcement 
of the 1964 Civil Rights Act, deserve much of the credit for improved 
access among low-income families, the elderly, and the disabled. Yet 
disparities in the health of the U.S. population persist and our health 
system inadequately cares for some and excludes millions of others.
    My testimony today focuses on the role of health insurance in 
reducing disparities in healthcare and in health status, two distinct 
but related challenges. Disparities in healthcare--whether in insurance 
coverage, access, or quality of care--are one of many factors producing 
inequalities in health status in the U.S. Eliminating disparities in 
health among segments of the population (e.g., by race/ethnicity, 
education, income, gender, geographic location) was one of two 
overarching goals of Healthy People 2010, the Federal Government's 
blueprint for what it wanted to achieve in health by the end of this 
decade.
    Let me begin with several examples of the urgency of these goals 
with two examples reflecting longstanding disparities, and one 
reflecting a more recent occurrence of a pattern of excess burden of 
disease that is unacceptable in a nation with the economic resources 
and technological know-how of the U.S. (Figures 2-4).

      A baby born to a Native American woman with a high school 
degree is almost twice as likely to die during the first year of life 
as a baby born to a Hispanic woman with the same years of education 
(9.2 vs. 5.3 per 1000 live births)
      A Black man earning less than $10,000 has a life 
expectancy at age 25 that is 3 years less than a White man earning the 
same income; and
      The rate of new AIDS cases among adults/adolescents is 3 
times higher among Hispanics (26 per 100,000) than the rate among 
Whites (7 per 100,000).

    Although the causes of health disparities are complex and result 
from multiple interrelated factors (some individual and some societal), 
differentials in access to care and in the quality of care contribute 
to these health disparities. Access to quality care matters. The extent 
to which medical care contributes to health outcomes may be relatively 
small when overall population mortality is the measure of health 
outcome (McGinnis et al 2002); however, the effects of medical care can 
be immeasurable for individuals with specific health problems such as 
asthma or heart disease or who need the guidance of the health system 
to help change personal behaviors. Nonetheless, efforts to address 
healthcare disparities are important for reasons far beyond their 
impact on health outcomes.
Why Addressing Healthcare Disparities is Important
    The racial divides in the United States--whether in education, 
employment or healthcare--reflect the Achilles heel of this nation. 
Healing the wounds that separate this nation is important if we are to 
move forward as one nation. The U.S. was founded on ideals of equality 
of opportunity and continuing efforts to realize those goals are 
warranted throughout all sectors of society. In the health system, 
assuring that individuals with similar healthcare needs are similarly 
treated is a basic matter of fairness.
    The landmark IOM report, Unequal Treatment, provided compelling 
evidence that racial disparities in care persist. However, national 
surveys continue to show that a sizable share of the population is 
unaware that all Americans don't receive the same access to medical 
care (Figure 5). Some of the disbelief is rooted in concerns about the 
quality of the evidence on racial disparities (i.e., whether the 
problem is real or largely explained by socio-economic differences in 
the population).
    About five years ago, the Foundation working in partnership with a 
number of physician groups launched a campaign ``Why The Difference'' 
in an effort to increase awareness of healthcare disparities and 
ultimately encourage efforts to address them. We learned that the 
disbelief about whether a problem exists also extended to physicians. 
As such, a major component of the initiative was a thorough review of 
studies on racial differences in the care of patients with heart 
disease. We drilled down to the best studies designed to control for 
differences in heart disease severity, as well as socioeconomic status. 
The review, undertaken with the American College of Cardiology 
Foundation and Association of Black Cardiologists, provided credible 
evidence of lower rates of diagnostic and revascularization procedures 
for at least one of the minority groups under study in eight out of ten 
studies. This finding held true whether reviewing all studies meeting 
criteria for the review, the subset of studies defined as the most 
methodologically rigorous or that analyzed only clinical data (Figure 
6). A number of efforts are now underway to improve the quality of 
cardiac care and reduce disparities in care, including one funded by 
the Robert Wood Johnson Foundation that is showing evidence of success.
The Role of Insurance in Racial Disparities in Care
    Health insurance coverage provides the financial means to access 
care in the U.S. Whether or not one has health insurance or adequate 
insurance for their medical needs is linked to a number of factors 
including age, employment, state of residence, and even race/ethnicity.
    Of the 47 million nonelderly Americans uninsured in 2006, 
approximately half--24 million--are people of color (Figure 7). While 
younger adults are more likely than older adults to be uninsured, older 
adults, especially the near-elderly (adults age 55-64) are a 
particularly vulnerable group because health problems increase with 
age. A racial disparity in coverage also exists among Americans ages 
55-64. For example, in 2006, 23 percent of American Indian/Alaska 
Natives and 19 percent of African Americans ages 55-64 were uninsured, 
as compared with 10 percent of Whites in that age group (Figure 8). 
This disparity has consequences for Medicare costs since many of the 
uninsured in this age group will have unmet needs for medical care upon 
entering Medicare at age 65.
    Insurance matters for adults of all ages. Uninsured adults across 
racial/ethnic groups are at least twice at likely as the insured to go 
without a doctor visit in the past year (Figure 9). Among Hispanic 
adults, for example, 21 percent of the insured had no doctor visit in 
the past year as compared with 53 percent of the uninsured. Numerous 
studies show that the consequences of being uninsured can be serious. 
When compared with the insured, the uninsured are less likely to have a 
regular doctor, and are more likely to be hospitalized for preventable 
conditions.
    Medicare provides insurance coverage for virtually all persons ages 
65 and older and for 7 million younger adults with permanent 
disabilities who qualify for Social Security. However, racial/ethnic 
differences in supplemental coverage among Medicare beneficiaries also 
can affect differentials in care. An estimated 18 percent of African 
Americans compared to 11 percent of Latinos and 11 percent of White 
Medicare beneficiaries lack supplemental coverage to fill in the gaps 
and pay for services not covered by Medicare (Figure 10). In addition, 
because Medicare beneficiaries of color are disproportionately low-
income, they are more likely than Whites to have supplemental coverage 
from Medicaid and thus are greatly affected by federal-state Medicaid 
policies that influence access to care. Without insurance or adequate 
insurance coverage, access to medical care suffers and can ultimately 
compromise one's health.
    In a review of multiple studies on the contribution of health 
insurance to racial disparities in care, health insurance was found to 
be the single largest factor explaining racial disparities in whether 
an individual had a regular source of medical care (Lillie-Blanton & 
Hoffman 2005). For example, one study in that review found that health 
insurance explained approximately 42 percent of the access disparity 
between African Americans and Whites, and about 20 percent of the 
access disparity between Hispanics and Whites in having a regular 
source of medical care (Figure 11), a well recognized measure of one's 
ability to obtain access to timely and quality care.
Disparities in Care Among the Insured
    Although the uninsured are clearly the most vulnerable for getting 
less than adequate care, disparities in access and in quality of care 
exist even among the insured. Evidence of racial/ethnic disparities in 
care among individuals who are similarly insured is particularly 
disturbing.
    The National Academy of Social Insurance recently completed a study 
panel on Medicare and racial disparities (NASI 2006). After a review of 
the research, the panel concluded that racial disparities exist not 
only among the privately insured but also among Medicare beneficiaries 
in fee-for-service and managed care. One study cited in the report 
analyzed Healthcare Effectiveness Data Information Set (HEDIS) measures 
for elderly White and Black beneficiaries enrolled in Medicare managed 
care plans between 1997 to 2003 (Trivedi et al 2005). The study found 
that the White-Black gap narrowed for seven of nine HEDIS measures but 
was not eliminated in any category, and it widened for two measures: 
glucose control among patients with diabetes and cholesterol control 
among patients with heart conditions. Another study of Medicare 
patients with breast, colorectal, lung, and prostate cancers shows that 
disparities persist in treatment of these conditions as well (Gross et 
al 2008).
    Evidence from the Medicare program also provides a positive example 
of how expansion in insurance coverage can diminish healthcare 
disparities (Daumit and Powe 2001). A nationwide study found that the 
racial disparity in cardiac procedure use among patients with chronic 
renal disease--a group at high risk for heart disease--was sharply 
reduced after patients qualified for Medicare (Figure 12). African 
American men and women were a third as likely as White men (the study 
reference group) to receive catheterization, angioplasty, and bypass 
surgery before enrolling in Medicare. After enrolling in Medicare and 
entering into a comprehensive system of care, there was no difference 
in cardiac procedure use between African American women and White men. 
For African American men, however, the disparity persisted. In other 
words, insurance coverage reduced the disparity for both population 
groups, and eliminated it for one population group.
Tools for Tracking Changes in Healthcare Disparities
    One of the most important tools for tracking disparities in access 
and quality of care is the annual National Healthcare Disparities 
Report (NHDR), which examines differences in patterns of care across 
different segments of the population. The 2007 NHDR shows that 
disparities between racial/ethnic groups continue to exist for a number 
of conditions and services and that progress in reducing disparities 
has been modest at best. The NHDR found that there was either no change 
or worsening of disparities in quality on more than half (57%-69%) of 
the 16 indicators tracked over time for the four racial/ethnic groups 
of color compared to Whites (Figure 13).
    It is important to note, however, that of the 42 quality indicators 
included in the 2007 NHDR, data on only 16 indicators were available to 
track over time for all racial/ethnic and income groups. Increasing our 
knowledge on healthcare disparities and effective interventions will 
require routinely collecting, analyzing, and reporting on data on 
healthcare use across population demographic characteristics such race/
ethnicity, income and education. These efforts are needed to benchmark 
and track our healthcare system's performance in serving all Americans, 
regardless of their background characteristics or where they live.
Race and Coverage Matter, but so do Other Factors
    Race and ethnicity clearly matter in our health system, but so do 
many other factors--such as the geographic availability of health 
services or the language capability of the provider. We live in a 
society that remains highly residentially segregated by race/ ethnicity 
and by income. People of color tend to live in close proximity to each 
other and people of limited financial means and those of great wealth 
tend to live in the same neighborhoods. As a result, education, 
employment, and healthcare opportunities tend to cluster along those 
divides. This reality complicates our ability to neatly define the 
causes of the problems or their solutions.
    The wealth of evidence, however, that insurance makes a difference 
in opening the door to the health system suggests that reducing the 
number of uninsured would be one effective first step in reducing 
racial/ethnic disparities in care. African Americans, Latinos, Native 
Americans, and some Asian and Pacific Islander Americans are 
disproportionately uninsured, and thus will face greater financial 
burden in obtaining access to care. Racial disparities among persons 
who are insured, however, are an indication that expansions in 
coverage, though necessary, are not sufficient. Efforts are needed to 
increase the knowledge base of what works and then apply that knowledge 
to help close the gap. Finally, collecting data to better track 
performance measures on our health system is important to monitor our 
progress in reducing disparities in care.

                                 

    I appreciate the opportunity to testify before the 
Committee today and welcome your questions. Thank you.
    Chairman STARK. Dr. Akhter, who is the Director of the 
National Medical Association, we are happy to have you here and 
look forward to your testimony.

 STATEMENT OF MOHAMMAD AKHTER, M.D., MPH, EXECUTIVE DIRECTOR, 
                  NATIONAL MEDICAL ASSOCIATION

    Dr. AKHTER. Thank you, Mr. Chairman and Members of the 
Committee. It is honor to testify before you on this very 
important subject not only to our community but to our Nation.
    National Medical Association's 30,000 physicians provide 
every single day services to the minority community, so what I 
am about to tell you is the reality on the ground.
    The first and most important contributing factor to the 
disparities is lack of affordable care. When the healthcare is 
not available, one out of three Hispanics and one out of four 
African Americans have no access to care. When the care is not 
available, they can't access the care in a timely manner. Then 
a small problem becomes a big problem. Like in our Nation's 
capital, a child who couldn't get dental care, the dental 
abscess became the brain abscess and the child died. And there 
are many examples like this. So access to care becomes the 
number one issue for our minority communities.
    Even when we do have health insurance, people have 
difficulty getting the access because there are not many 
providers in those communities. Why would a provider open his 
office in a community where every third person coming in is 
uninsured or has no ability to pay? And so when there is no 
provider or very few providers, people are having difficulty 
getting care, even for Medicare patients.
    Fifty percent of the Medicare patients in a study done by 
Hopkins shows they have difficulty finding a general 
practitioner to be taking care of their diabetes, their 
hypertension; and 81 percent of the patients have no access to 
mental health services. So, without these services, it really 
becomes very, very hard.
    So in areas of our country when people do have insurance 
and people do have access, they usually receive poor quality 
care in the minority communities. And one big reason for 
receiving poor quality care is a lack of coordination between 
the providers. Most minority patients with multiple chronic 
conditions have many doctors and many providers. They don't 
talk to each other.
    So in this one study by Hopkins, 32 percent of the patients 
got conflicting medical advice from their providers. Twenty-
five percent of the time they had to have duplicate tests done, 
and another 25 percent of the time they got wrong prescriptions 
or conflicting prescriptions. So no wonder 71 percent of 
Hispanics and over 50 percent of African Americans are 
dissatisfied with the care they receive when they go to get the 
care.
    Mr. Chairman and Members of the Committee, the system is 
broken. We need to fix the system.
    And when everything is available--the people have 
insurance, they have access to care, there are great 
institutions--the culturally competent care is not available. 
The language problem, low literacy rates, the communication 
between the doctor or the provider and the patient is not very 
good, so the treatment plan that's developed is not followed by 
the patient appropriately. So, as a result, despite our 
spending a lot of money in the healthcare delivery system, we 
continue to have these disparities.
    And finally, Mr. President, when the system was put in 
place in the last century, in our Nation life expectancy was 
around 50 years, and most our people were of European descent. 
So the system put in place was for the sick care system or the 
acute care system. It has served us very well over the years.
    But now our Nation has changed. Our population has grown 
older. Our society has become multicultural, multiethnic, and a 
bigger problem for our society is the chronic care, management 
of care. Seventy-five percent of the problem is management of 
chronic care. That is where the disparities come in. This acute 
care system is not designed to do deal with chronic care 
problems. So we need to transform the system from a sick care 
system to a healthcare system that includes prevention, disease 
management that is patient centered and is affordable.
    Mr. Chairman, I know you've been very interested in this 
issue and the Members of the Committee, but really truly to 
address this issue not only we need to follow through on the 
TriCaucus bill but we also need to transform our healthcare 
delivery system so it could meet the needs of our population as 
it exists today and as it will be in the future.
    I thank you very much for the opportunity today, Mr. 
Chairman, to testify before you.
    Chairman STARK. Thank you, Doctor.
    [The prepared statement of Dr. Akhter follows:]
           Prepared Statement of Mohammad Akhter, M.D., MPH,
            Executive Director, National Medical Association

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman STARK. I guess it's Ms. Jang, who is the Policy 
Director of the Asian and Pacific Islander American Health 
Forum. Would you like to enlighten us, please?

  STATEMENT OF DEEANA JANG, J.D., POLICY DIRECTOR, ASIAN AND 
             PACIFIC ISLANDER AMERICAN HEALTH FORUM

    Ms. JANG. Thank you. I guess I am a doctor, because I have 
a J.D.
    But I want to thank you Chairman Stark, Ranking Member Camp 
and Members of the House Ways and Means Subcommittee on Health 
for inviting me to testify on disparities in health and 
healthcare and for your leadership on healthcare reform, 
especially your efforts to address health equity.
    The Asian and Pacific Islander American Health Forum is a 
national advocacy organization dedicated to improving the 
health and well-being of Asian Americans and Pacific Islander 
communities through policy, programs, and research. My 
testimony this morning will discuss the disparities in 
healthcare coverage, health status, access to care, and quality 
of care for Asian Americans and Pacific Islanders. I will end 
by discussing some important policy proposals included in the 
House-passed CHAMP Act and H.R. 3014, the TriCaucus-sponsored 
health equity legislation.
    Earlier today, Ms. Bordallo discussed the heterogeneity of 
Asian American and Pacific Islander communities in terms of 
ethnicities, languages spoken, culture, and socioeconomic 
status. As a group, Asian Americans and Pacific Islanders are 
more likely to be uninsured than nonHispanic whites. Specific 
Asian American and Pacific Islander groups face extremely high 
rates of uninsurance. For example, 24 percent of Native 
Hawaiians and Pacific Islanders and 31 percent of Korean 
Americans are uninsured.
    The sources of insurance also varies greatly between Asian 
American and Pacific Islander subgroups. Southeast Asians have 
higher incidents of poor and near poor and are more likely to 
rely on Medicaid and the State Children's Health Insurance 
Program. Koreans, who are more likely to work in their own 
small businesses, are less likely to have employer-sponsored 
health coverage.
    Any healthcare reform coverage that includes employer 
mandates must take into consideration the need for affordable 
health coverage for small business owners, and expanding public 
programs to cover more low-income individuals will also result 
in expanded coverage for Asian Americans and Pacific Islanders.
    While health insurance coverage is an important predictor 
of access to healthcare in our communities, uninsured Asian 
Americans were more than four times as likely as insured Asian 
Americans to lack a usual source of care. However, disparities 
and access to care remain, regardless of healthcare coverage. 
Factors such as language and cultural barriers prevent many 
Asian Americans and Pacific Islanders from accessing quality 
care. For example, cancer is the leading cause of death among 
Asian Americans; yet Asian Americans were significantly less 
likely to receive preventative services such as cancer 
screenings or cholesterol checks or counseling about smoke 
cessation, diet, weight, exercise, and mental health.
    There are two important strategies included in the CHAMP 
Act and H.R. 3014 that I want to highlight that should be 
included in any efforts to reform healthcare. First of all, 
standardizing the collection, analysis and reporting of data on 
race, ethnicity, and primary language in an accurate and 
appropriate manner and, secondly, ensuring that effective 
communication takes place between provider and patient through 
the provision of competent language assistance.
    Accurate, timely disaggregated data by race, ethnicity, and 
primary language on Asian Americans and Pacific Islanders and 
other racial and ethnic minorities are vital to developing and 
monitoring programs and policies aimed at improving health 
equity. Medicare data has provided a rich source of information 
about these populations and the disparities in health and 
healthcare among Medicare beneficiaries.
    You have heard about the Robert Wood Johnson study that was 
mentioned earlier, but there has also been a recent study that 
found that, although there were variations related to geography 
and socioeconomic status overall, Asian Medicare beneficiaries 
were less likely than whites to receive mammography and 
colorectoral cancer screening and all three diabetic services.
    And while there have been some improvements in the quality 
of data collected on race and ethnicity, there remains much 
more to be done. For example, the improvement in the data on 
race, ethnicity, and primary language in the Medicare system. 
The problem is that Medicare's data comes from the Social 
Security Administration, and this data is collected at the time 
that someone applies for a Social Security number. The problem 
is that the way that data is collected has not been updated to 
conform with the OMB revised standards in 1997 on the 
collection of race and ethnicity.
    The second problem is the Enumeration at Birth process. 
That doesn't provide data on race and ethnicity.
    And, finally, 12 percent of Medicare beneficiaries are 
enrolled by Medicare health plans that are not required to 
collect or report data on race, ethnicity, or primary language.
    Finally, in terms of language access, almost all health 
providers are obligated by the Civil Rights Act to provide 
language assistance, but we need more technical assistance and 
resources to pay for it. So while the Centers for Medicare and 
Medicaid Services has clarified that language services are 
reimbursable in the Medicaid and SCHIP program, no such 
reimbursement is specifically available in the Medicare 
Program. And although Medicare health plans are required to 
provide the language services, most of them are passing those 
obligations on to their contractor providers without any 
reimbursement or resources to help them do that. So we support 
the provisions in the CHAMP Act that will call for a study and 
evaluations and demonstration projects to assure that high-
quality language assistance is provided in a cost-effective 
manner with incentives for providers to use it.
    I thank you for the invitation, again, to testify. There is 
more data and details in my written statement, and I would be 
happy to answer any questions.
    Chairman STARK. Thank you very much.
    [The prepared statement of Ms. Jang follows:]
       Prepared Statement of Deeana Jang, J.D., Policy Director,
             Asian & Pacific Islander American Health Forum
    Thank you, Chairman Stark, Ranking Member Camp, and Members of the 
House Ways and Means Subcommittee on Health, for inviting me to testify 
on disparities in health and healthcare. I also want to thank Chairman 
Stark and Members of this Subcommittee for your leadership on 
healthcare reform and for your efforts to address health equity within 
the context of reform.
    The Asian and Pacific Islander American Health Forum, or ``Health 
Forum,'' is a national advocacy organization dedicated to improving the 
health and well-being of Asian American and Pacific Islander (AA and 
PI) communities through policy, programs, and research. We advocate on 
health issues that impact AA and PI communities, provide community-
based technical assistance and training to address chronic diseases, 
HIV/AIDS, and domestic violence in AA and PI communities, and convene 
regional and national conferences on AA and PI health.
    Healthcare reform, or expanding access to healthcare for uninsured 
and underinsured Asian Americans and Pacific Islanders (AAs and PIs), 
is one of five major policy priorities for the Health Forum. But, as 
you'll see from my testimony, even with health coverage, disparities in 
health and healthcare persist in our communities. My testimony will 
also cover some of the unique factors that make it difficult for AAs 
and PIs to access quality healthcare; such as disparities in health 
coverage due to poverty, and a significant percentage who work in or 
own small businesses and barriers due to language and culture.
Disparities in Health Coverage among AAs and PIs
    As a group, Asian Americans and Pacific Islanders are more likely 
to be uninsured than non-Hispanic whites. Specific AA and PI groups 
face extremely high rates of uninsurance: from 2004-2006, 24 percent of 
Native Hawaiians and Pacific Islanders and 31 percent of Korean 
Americans were uninsured.\1\
---------------------------------------------------------------------------
    \1\ Kaiser Family Foundation and Asian & Pacific Islander American 
Health Forum, Health Status, Coverage, and Access to Care for Asian and 
Native Hawaiian and Pacific Islander Americans (Washington, DC: April 
2008).
---------------------------------------------------------------------------
    The high rate of uninsurance in several Asian American communities 
is related to their employment in small businesses that do not offer 
health insurance benefits. For example, more than half of Korean 
Americans work in businesses with less than 25 employees. Yet, only 
half of employees in such firms are provided coverage through their 
employer. As a result, Korean Americans have one of the lowest rates of 
employer-sponsored health coverage among AAs and PIs, 49 percent, 
compared to South Asians who have the highest rate at 75 percent.\2\ By 
providing small businesses with affordable options, healthcare reform 
efforts could significantly lower the number of uninsured AAs and PIs.
---------------------------------------------------------------------------
    \2\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
    Public programs such as Medicaid and SCHIP also play an important 
role in reducing uninsurance in AA and PI communities. Gains in 
coverage by these programs, between 1997 and 2004-2006, helped protect 
AAs and PIs from declines in job-based coverage. This helped decrease 
the number of uninsured AAs and PIs from 21 percent to 19 percent over 
that same period.\3\ An expansion of public programs through healthcare 
reform efforts is critical for individuals who do not have access to 
affordable coverage through an employer or the private market.
---------------------------------------------------------------------------
    \3\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
    Coverage of AAs and PIs in public programs grew in part due to 
federal and state efforts over the last decade to reduce barriers faced 
by minority and immigrant communities. Many AAs and PIs qualify for 
public programs but remain uninsured because of language and cultural 
barriers in the enrollment process, misinformation about eligibility, 
and other family hardships such as food and housing insecurity. There 
are others who do not qualify even if they are low-income and legal 
immigrants. Since 1996, legal immigrants in low-income families have 
been barred from receiving Medicaid or SCHIP during their first five 
years in this country, even if they meet all other requirements for the 
programs. Citizens of the Republic of the Marshall Islands (RMI), the 
Federated States of Micronesia (FSM), and the Republic of Palau are 
ineligible for public programs as well, even though they are allowed to 
work and travel in the U.S.
    To address these disparities in coverage, many states developed 
strategies to help enroll individuals with limited English proficiency 
in Medicaid and SCHIP.\4\ States also took additional steps to simplify 
enrollment and renewal procedures for children.\5\ And, nearly half of 
states have continued to provide coverage for legal immigrants during 
their first five years in the country through state-funded programs.\6\ 
Ensuring that similar solutions are enacted through healthcare reform 
would help eliminate the health insurance disparities faced by AA and 
PI communities.
---------------------------------------------------------------------------
    \4\ M. Youdelman, J. Perkins and J. Brooks, Providing Language 
Services in State and Local Health-Related Benefits Offices: Examples 
from the Field, (New York: The Commonwealth Fund, January 2007).
    \5\ Kaiser Family Foundation, Health Coverage for Children and 
Families in Medicaid and SCHIP: State Efforts Face New Hurdles: A 50 
State Update on Eligibility Rules, Enrollment and Renewal Procedures, 
and Cost Sharing Practices in Medicaid and SCHIP in 2008, (Washington, 
DC: January 2008).
    \6\ L. Ku, Reducing Disparities in Health Coverage for Legal 
Immigrant Children and Pregnant Women, (Washington, DC: Center on 
Budget and Policy Priorities, April 2007).
---------------------------------------------------------------------------
Disparities in Access to Care
    Health insurance coverage is an important predictor of access to 
healthcare in AA and PI communities. From 2004 to 2006, uninsured Asian 
Americans were more than 4 times as likely as insured Asian Americans 
to lack a usual source of care.\7\
---------------------------------------------------------------------------
    \7\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
    However, disparities in access to care remain regardless of health 
coverage. Nonelderly AAs and PIs were more likely to lack a usual 
source of care than non-Hispanic Whites (18 percent vs. 14 percent).\8\ 
Similarly, 52 percent of nonelderly uninsured AAs and PIs lacked a 
usual source of care, compared to 46 percent of non-Hispanic uninsured 
Whites. Factors such as language and cultural barriers prevent many AAs 
and PIs from accessing quality care.
---------------------------------------------------------------------------
    \8\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
Disparities in Quality of Care
    Findings from the Commonwealth Fund's 2001 Healthcare Quality 
Survey concluded that Asian Americans experience poor access to quality 
care on a range of measures.'' \9\ Asian Americans reported greater 
communication difficulties and lower levels of satisfaction during 
their healthcare visits.\10\ They were also ``the least likely to feel 
that their doctor understands their background and values, to have 
confidence in their doctor, and to be as involved in decision-making as 
they would like to be.'' \11\
---------------------------------------------------------------------------
    \9\ K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K. 
Tenney, Diverse Communities, Common Concerns: Assessing Healthcare 
Quality for Minority Americans: Findings from the Commonwealth Fund 
2001 Healthcare Quality Survey, (New York: The Commonwealth Fund, March 
2002).
    \10\ Collins et al, Diverse Communities, Common Concerns, 2002.
    \11\ Collins et al, Diverse Communities, Common Concerns, 2002.
---------------------------------------------------------------------------
    Despite having higher rates of certain health conditions, many AAs 
and PIs do not receive the recommended levels of prevention, 
counseling, or care they need. The 2001 and 2006 Healthcare Quality 
Surveys revealed that Asian Americans were significantly less likely to 
receive preventive services such as cancer screenings or cholesterol 
checks, or counseling about smoking cessation, diet, weight, exercise, 
and mental health.\12\ Less than half of Asian Americans with chronic 
conditions received the care they needed to manage their 
conditions.\13\
---------------------------------------------------------------------------
    \12\ Collins et al, Diverse Communities, Common Concerns, 2002. A. 
Beal, M. Doty, S. Hernandez, K. Shea, and K. Davis, Closing the Divide: 
How Medical Homes Promote Equity in Healthcare,'' (New York: The 
Commonwealth Fund, June 2007).
    \13\ Beal et al, Closing the Divide, 2007.
---------------------------------------------------------------------------
Disparities in Health Outcomes and Disease Prevalence
    The lack of health coverage, limited access to healthcare, and the 
lack of culturally and linguistically competent services can manifest 
in harmful, and even fatal ways:

      Cancer deaths are increasing at a faster rate among AAs 
and PIs than any other racial and ethnic population. For example, the 
risk of death for Asian American women with breast cancer is 1.5 to 1.7 
times higher than that for white women.\14\ This is due in part to the 
relatively low screening rates and late stage diagnoses that occur 
among AA and PI women.
---------------------------------------------------------------------------
    \14\ C. Chappell, ``Healthcare Needs of Asian American Women,'' 
Issues, Concerns, and Responsive Human and Civil Rights Advocacy: Asian 
American Women, Second Edition, Chapter 5, pages 101-120, 2007.
---------------------------------------------------------------------------
      Although statistics on the overall prevalence of diabetes 
in AA and PI communities are unavailable, it is the fifth leading cause 
of death among AAs and PIs. In Hawaii, AAs and PIs aged 20 and over are 
more than 2 times as likely to have diagnosed diabetes as whites after 
adjusting for population age differences. In California, Asian 
Americans are 1.5 times as likely to have diagnosed diabetes as non-
Hispanic whites. Despite the importance of managing diabetes, nearly 
half of AA and PI adults with diabetes in California had not received a 
foot exam in the past year, compared with less than 30 percent of 
Whites and African Americans.\15\
---------------------------------------------------------------------------
    \15\ Centers for Disease Control and Prevention, National Diabetes 
Fact Sheet, United States, 2005.
---------------------------------------------------------------------------
      Asian American women aged 15-24 and over 65 have the 
highest suicide rates across all racial and ethnic groups.\16\ 
Furthermore, Asian American girls have the highest rates of depression 
across both race/ethnicity and gender.\17\ The U.S. Surgeon General 
noted in 2001 that nearly half of AAs and PIs have problems accessing 
mental health services because of the lack of providers with 
appropriate language skills.\18\
---------------------------------------------------------------------------
    \16\ Centers for Disease Control and Prevention, ``Deaths: Leading 
Causes for 2001,'' National Vital Statistics Reports, 52(9), 1-86, 
2003.
    \17\ National Center for Health Statistics, ``Health, United 
States, 2003,'' (Hyattsville, MD: U.S. Public Health Service, 2003).
    \18\ U.S. Surgeon General. 2001. Mental Health: Culture, Race, and 
Ethnicity. A Supplement to Mental Health: A Report of the Surgeon 
General. Washington, DC: U.S. Department of Health and Human Services.
---------------------------------------------------------------------------
Strategies to address disparities in coverage, access and quality
    There are two important strategies included in Subtitle D of H.R. 
3162, the Children's Health and Medicare Protection Act of 2007 (CHAMP 
Act) that should be included in healthcare reform initiatives to 
address disparities in coverage, access and quality:

    1.  Standardizing the collection, analysis and reporting of data on 
race, ethnicity and primary language in an accurate and appropriate 
manner.
    2.  Ensuring that effective communication takes place between 
provider and patient through the provision of competent language 
assistance.

Importance of collection of data on race, ethnicity and primary 
        language
    Accurate, timely, disaggregated data by race, ethnicity, and 
primary language on Asian Americans and Pacific Islanders are vital to 
developing and monitoring programs and policies aimed at improving 
health equity.
    In 1999, Congress requested that the Institute of Medicine (IOM) 
assess the extent of health disparities; explore factors that may 
contribute to inequities in care; and recommend policies and practices 
to eliminate them. Its report, ``Unequal Treatment: Confronting Racial 
and Ethnic Disparities in Healthcare,'' found significant disparities 
in the quality of health services received by minorities--even when 
insurance status, income, age, and severity of condition were 
comparable. The IOM study further revealed that minorities are less 
likely to be given appropriate cardiac medications, undergo bypass 
surgery, and receive kidney dialysis or transplants. Sadly, they are 
also more likely to receive last-resort procedures, such as lower limb 
amputations for diabetes. Subsequent research suggests that these 
disparities continue to this day for both minorities and women. For 
example, a recent study released by the Robert Wood Johnson Foundation 
found that the rate of leg amputation is four times greater in African 
American Medicare beneficiaries than in whites.\19\
---------------------------------------------------------------------------
    \19\ E. Fisher, D. Goodman, and A. Chandra, Disparities in Health 
and Healthcare among Medicare Beneficiaries: A Brief Report of the 
Dartmouth Atlas Project, The Robert Wood Johnson Foundation, June 2008.
---------------------------------------------------------------------------
    To help close the disparity gap, the IOM recommended that the 
Federal Government: (1) collect and report data on healthcare access 
and utilization by patients' race, ethnicity, and socioeconomic status; 
(2) include measures of disparities in performance measures; and, (3) 
monitor progress toward the elimination of healthcare disparities. In 
2001, the Commonwealth Fund went a step further by recommending that 
quality measurement and reporting tools, such as the Health Plan 
Employer Data and Information Set collect and report health data by 
race, ethnicity, and primary language. However, no comprehensive action 
has been taken on these recommendations; it is long overdue.
    A recent study published in Health Affairs found that, although 
there were some variations related to geography and socioeconomic 
status, overall, Asian Medicare beneficiaries were less likely than 
whites to receive mammography and colorectoral cancer screening 
services and all three diabetic services.\20\ The National Healthcare 
Disparities Report in 2006 found that Asians receive lower quality of 
care compared with whites for one-third of the core measures tracked in 
the report, and for 75 percent of those measures, the gaps in quality 
were not improving over time.\21\
---------------------------------------------------------------------------
    \20\ E. Moy, L. Greenberg, and A. Borsky, Community Variation: 
Disparities in Healthcare Quality Between Asian and White Medicare 
Beneficiaries, Health Affairs, Vol. 27, No. 2, March/April 2008.
    \21\ Agency for Healthcare Research and Quality, 2006 National 
Healthcare Disparities Report, December 2006.
---------------------------------------------------------------------------
    Medicare data has provided a rich source of information about 
racial, ethnic, and socioeconomic disparities in health and healthcare 
among Medicare beneficiaries. And while there have been some 
improvements in the quality of data collected on race and ethnicity, 
there remain much more that needs to be done to improve the quality and 
accuracy of data. For example, an analysis of 2002 Medicare 
administrative data show that only 52 percent of Asian beneficiaries 
and 33 percent of both Hispanic and American Indian/Alaska Native 
beneficiaries were identified correctly.\22\
---------------------------------------------------------------------------
    \22\ A. McBean, Improving Medicare's Data on Race and Ethnicity, 
Medicare Brief, No. 15, National Academy of Social Insurance, October 
2006.
---------------------------------------------------------------------------
    Medicare's data on race and ethnicity come from Social Security's 
administrative records and are collected on a consistent basis when an 
individual applies for a Social Security number. The way the data is 
collected was not (and has not been) updated when the Office of 
Management and Budget revised the standards for collection of race and 
ethnicity data in 1997. In addition, since the late 1980's, most 
applications for Social Security numbers are made through the 
Enumeration at Birth process, and questions regarding race and 
ethnicity are not included. Finally, 12 percent of Medicare 
beneficiaries are enrolled by Medicare health plans that are not 
required to collect or report data on race, ethnicity or primary 
language.\23\
---------------------------------------------------------------------------
    \23\ A. McBean, op. cit.
---------------------------------------------------------------------------
    APIAHF is part of the Out of Many, One (OMO) Data Task Force, a 
coalition of advocates working to eliminate racial and ethnic health 
disparities. At the request of OMO, the Congressional Tri-Caucus has 
sent a letter to the Social Security Administration requesting 
information on the status of its efforts to improve data collection on 
race, ethnicity and primary language. OMO and APIAHF are also 
supporting language in pending Medicare legislation in the Senate to 
grant authority to the Secretary of Health and Human Services to 
require Medicare plans and providers to report race, ethnicity, and 
gender-specific data as part of the quality measures they are currently 
required to collect and report. Such provisions would help identify and 
eliminate disparities in the quality of health services that minorities 
and women enrolled in the program receive.
    The provisions included in Subtitle D of H.R. 3162, the Children's 
Health and Medicare Protection Act of 2007 (CHAMP Act) will 
substantially improve the collection of data on race, ethnicity and 
primary language. Specifically, we support:

      Collection of data on race, ethnicity, and primary 
language of each applicant for and recipient of Medicare benefits in 
conformity with the 1997 revised OMB standards and further 
disaggregation, where practicable, for additional population groups.
      Development of standards for collection of data on 
primary language spoken and written of Medicare beneficiaries.
      Technical assistance for health information technology 
improvements that will facilitate collection and analysis of racial, 
ethnic and primary language data; improving methods for collection and 
analysis of smaller populations and ethnic subgroups within the minimum 
OMB standards; and educating healthcare organizations, providers and 
health plans to raise awareness that collecting and reporting data on 
race, ethnicity and primary language are essential to eliminate 
disparities and is legal; and providing for the revision of the 
existing HIPAA claims-related code set to require collection of data on 
race and ethnicity and to provide a code set for the collection of 
primary language data.
      Identification of appropriate quality measures to monitor 
for disparities and to develop new quality measures related to racial 
and ethnic disparities in health and healthcare.

    We also support the provision in H.R. 3014, the Health Equity and 
Accountability Act of 2007, that requires the Social Security 
Administration to collect data on the race, ethnicity, and primary 
language of all applicants for social security numbers or benefits.
Ensuring that effective communication takes place between provider and 
        patient through the provision of competent language assistance.
    Language barriers can reduce access to healthcare, jeopardize the 
quality of care, lower patient satisfaction and adherence, increase the 
risk of medical errors and lead to other adverse outcomes. More than a 
third of Asian Americans and 12 percent of Pacific Islanders speak 
English less than very well. The rate of limited English proficiency is 
even higher for specific groups: more than half of Vietnamese, Hmong, 
Cambodian, Laotian, Bangladeshi, and Taiwanese are limited English 
proficient. Research indicates that the use of trained interpreters and 
especially the use of language concordant health providers can improve 
access to and quality of care for persons with limited English 
proficiency.\24\ Research also shows that Medicare beneficiaries who 
are limited English proficient in English are less likely than those 
who are proficient in English to have access to a consistent source of 
care and less likely to receive important preventive care, including 
cancer screening tests.\25\ However, more research is needed to 
determine the impact of language services on the health and healthcare 
of limited English proficient populations. We support the provision in 
H.R. 3162 that requires the Secretary of HHS to arrange for the 
Institute of Medicine to conduct a study of the effects of providing 
language access services on quality of healthcare, access to care and 
reduced medical error.
---------------------------------------------------------------------------
    \24\ Green, A., et al. ``Interpreter services, language 
concordance, and healthcare quality. Experiences of Asian Americans 
with limited English proficiency.'' J Gen Intern Med. 20(11):1050-6, 
Nov. 2005. Flores, G. ``The impact of medical interpreter services on 
the quality of healthcare: a systematic review.'' Med Care Res Rev. 
62(3):255-99, June 2005. Ngo-Metzger, Q. ``Providing high-quality care 
for limited English proficient patients: the importance of language 
concordance and interpreter use.'' J Gen Intern Med. 22 (Suppl 2):324-
30. Nov. 2007.
    \25\ N. Ponce, L. Ku, W. Cunningham, and E. Brown, Language 
Barriers to Healthcare Access Among Medicare Beneficiaries, Inquiry, 
Spring 2006.
---------------------------------------------------------------------------
Medicare programs should be ensuring that meaningful access to 
        enrollment and healthcare services is provided for persons with 
        limited English proficiency.
    Under Title VI of the Civil Rights Act of 1964, all recipients of 
Federal financial assistance are required to provide meaningful access 
to its programs, services and activities, including those that are not 
directly Federally funded, to persons with limited English proficiency. 
Not all Medicare programs are considered Federal financial assistance. 
While Medicare Part A providers are considered recipients of Federal 
financial assistance, providers (e.g. individual physicians, who only 
receive Medicare Part B and no other form of Federal financial 
assistance, e.g. Medicaid) are not obligated to comply with federal 
civil rights law.\26\ This has caused some confusion as new Medicare 
programs have been initiated with a mixture of Part A and Part B funds, 
e.g. Part C, and other sources so that determining whether participants 
in some Medicare programs are required to comply has become more 
complex. We support the provision in H.R. 3162 to require the HHS 
Inspector General to prepare and publish a report on the extent to 
which Medicare providers and plans are complying with Title VI and are 
providing culturally and linguistically appropriate services as 
described in the Office of Minority Health's Culturally and 
Linguistically Appropriate Services Standards in healthcare. In 
addition, we support requiring all Medicare providers to comply with 
Federal civil rights laws. This provision is included in Title I of 
H.R. 3014.
---------------------------------------------------------------------------
    \26\ U.S. Department of Health and Human Services, Office for Civil 
Rights, Guidance to Federal Financial Assistance Recipients Regarding 
Title VI Prohibition Against National Origin Discrimination Affecting 
Limited English Proficient Persons, 68 Fed. Reg. 47311, August 8, 2003.
---------------------------------------------------------------------------
    Furthermore, Executive Order 13166 requires that all Federal 
agencies develop plans to ensure that programs conducted by the Federal 
Government are accessible to persons with limited English 
proficiency.\27\ Therefore, outreach and enrollment in the Medicare 
program conducted by the Centers for Medicare and Medicaid Services 
(CMS) should be accessible for persons with limited English 
proficiency. We are concerned that while CMS translated much of the 
outreach materials for enrollment in the Medicare Part D program, there 
remain issues of inaccessibility to telephone assistance and enrollment 
materials. We are also concerned that Medicare informational materials, 
applications and beneficiary notices are not available in languages 
other than English and Spanish.
---------------------------------------------------------------------------
    \27\ Improving Access to Services for Persons with Limited English 
Proficiency, 65 Fed. Reg. 50121, August 16, 2000.
---------------------------------------------------------------------------
The Federal Government needs to provide reimbursement for the cost of 
        language assistance and provide technical assistance to 
        providers to ensure that high quality and effective language 
        assistance is available in a timely manner.
    Although CMS has clarified that states can get federal matching 
funds for the provision of language services in its Medicaid and State 
Children's Health Insurance Programs, language services are currently 
not specifically reimbursable by the Medicare program. Although the 
regulations for Medicare Advantage require managed care plans to 
``ensure that services are provided in a culturally competent manner to 
all enrollees, including those with limited English proficiency or 
reading skills, and diverse cultural and ethnic backgrounds,'' \28\ it 
is unclear whether and how Medicare Advantage plans are paying for 
language services and if they need or should have additional payments. 
Most managed care plans pass on the requirement to their contracted 
providers without specific funding or incentives. So while the managed 
care plans may have contractually agreed to provide language 
assistance, their payment policies may in fact create a disincentive 
for providers to participate and use language services.
---------------------------------------------------------------------------
    \28\ 42 C.F.R. 422.112(a)(8).
---------------------------------------------------------------------------
    Healthcare providers from across the country have reported 
inadequate funding of language services to be a major barrier to LEP 
individuals' access to healthcare and a serious threat to the quality 
of the care they receive.

      63% of hospitals encounter patients with LEP daily or 
weekly; an additional 17% encounter LEP patients at least monthly.
      65% of internal medicine physicians have active patients 
who are LEP.

    Almost every major health organization (including the AMA, AHA, 
ANA, AAP, AAFP, ACP, ANA, APHA, APA, NACHC, NAPH, NASW, NMA and NHMA), 
supports government payments for language services as necessary to 
ensuring quality healthcare. Over 75 organizations have endorsed the 
Language Services in Healthcare Statement of Principles which supports 
funding mechanisms to ensure language services are available where and 
when they are needed.

      The American College of Physicians recommends that 
Medicare should pay for the added expense of language services and the 
additional time in providing clinical care.
      The American Hospital Association stated that resources 
should be targeted to improving language services for all patients with 
LEP.
      According to a recent article in Pediatrics, discussing 
results from a survey of pediatricians supported by the American 
Association of Pediatrics, reimbursement for language services is 
associated with greater use of professional interpreters.

    We recognize that determining the best methodology and structure to 
provide reimbursement in the Medicare program is complex given the 
payment structure of the various providers, including in--and out-
patient hospital care, physician care and managed care. Therefore, the 
approach taken by H.R. 3162 to support a study and demonstration 
projects to examine the ways that Medicare should develop payment 
systems for language services is necessary to determine the most 
efficient, cost-effective way to ensure the provision of language 
services that includes incentives for providers and that result in 
effective communication between providers and LEP persons. The National 
Health Law Program together with the Center on Budget and Policy 
Priorities has already taken a preliminary look at this issue and we 
urge HHS to consider their report on ``Paying for Language Services in 
Medicare: Preliminary Options and Recommendations,'' October 2006. The 
major recommendations from the report are:

      Offer grants to hospitals, schools that train health 
professionals and community groups to increase the recruitment and 
training of bilingual and multilingual medical interpreters and 
clinicians.
      To improve language services in physician settings, 
provide Medicare reimbursements to in-person interpreters and develop a 
system of federal contracts for telephone interpretation firms.
      Improve monitoring and oversight of existing requirements 
to provide language services in Medicare managed care.
      Exempt language services from Medicare cost-sharing 
requirements.

Barriers to participation in Federal healthcare programs must be 
        removed for immigrants and other noncitizens
    In order to ensure coverage and access to healthcare for all, 
federal programs including Medicare, Medicaid and the State Children's 
Health Insurance Program (SCHIP) must remove barriers to eligibility 
for immigrants and other noncitizens.
    We support the provisions in the CHAMP Act and H.R. 3014 to allow 
states to cover lawfully residing immigrant children and pregnant women 
in SCHIP and Medicaid. H.R. 3014 also provides eligibility for Medicaid 
and SCHIP for citizens of RMI, FSM and the Republic of Palau. In 
addition, other barriers such as excessive citizenship documentation 
must be repealed. We support these provisions in H.R 3162 and H.R. 3014 
as well.
Conclusion
    We look forward to working with Congress and the new Administration 
to achieve our mutual goals of guaranteed, affordable, high quality 
care that is truly accessible and equitable to all.
BOARD OF DIRECTORS
2008
Executive Committee

    Fatima Angeles, MPH
    Chairperson

    Ho Luong Tran, MD, MPH
    President/Chief Executive Officer

    Dexter Louie, MD, JD, MPA
    Treasurer

    Janice Louie, RD, BSPH, MA
    Secretary


    Rea Panares, MHS
    Vincent Hau, MD, PhD
    Senator Mee Moua
    Joyce O'Brien, MPH
    Sela Panapasa, PhD
    Wilson Wang, MD, MPA, MPH
Headquarters:
    450 Sutter Street
    Suite 600
    San Francisco CA 94108
    Main 415-954-9988
    Fax 415-954-9999
    www.apiahf.org
Washington D.C. Office:
    1828 L Street N.W.
    Suite 802
    Washington, D.C. 20036
    Main 202-466-7772
    Fax 202-466-6444

    National Advocates for
    Asian American,
    Native Hawaiian &
    Pacific Islander Health

                                 

    Chairman STARK. Dr. Iton, would you like to testify, 
please?

  STATEMENT OF ANTHONY B. ITON, M.D., J.D., MPH, DIRECTOR OF 
  PUBLIC HEALTH AND HEALTH OFFICER, ALAMEDA COUNTY, CALIFORNIA

    Dr. ITON. Good morning, Committee and certainly, Chairman 
Stark, as a practicing internist for the past 20 years, I have 
been very familiar with the Stark rules I and II, and it is an 
honor to be from a county that is represented by you and the 
leadership that you have shown in the Medicare Program.
    Good morning, Ranking Member Camp and Members Becerra and 
Jones.
    My name is Dr. Tony Iton. I am the Health Officer and 
Director of the Alameda County Public Health Department. I am a 
board-certified physician and an attorney, and I work in a 
department that serves about 1\1/2\ million people and have 
about 170,000 uninsured people in my county. Our combined 
agency expenditures are about $1 billion a year in healthcare.
    I recently had the privilege to participate in the creation 
of a multi-part PBS television documentary entitled Unnatural 
Causes: Is Inequality Making Us Sick? In concert with the 
national airing of that documentary series, my health 
department released a report on the preventable root causes of 
health disparities. We entitled our report Life and Death From 
Unnatural Causes: Health and Social Inequity in Alameda County, 
and with your permission, Chairman Stark, I would like to 
submit that report for the record.
    Chairman STARK. Without objection.
    [The information follows:]
    ******** COMMITTEE INSERT ********
    Dr. ITON. My testimony is largely based on research and 
data that appear in both the television series and the report 
as well as upon the experience of providing public health and 
healthcare services for the 1.5 million residents of Alameda 
County.
    Now, the focus of this hearing is healthcare disparities in 
the Medicare system. My particular input will be on the 
evidence that, while access to healthcare is a critical 
contributor to overall health status, the healthcare system by 
itself cannot successfully reduce health disparities and that 
unless greater attention is paid to public health approaches to 
reducing health and social inequity the Medicare system will be 
bankrupt due to the inexorable burden of chronic disease.
    I also try to address several false dichotomies and myths 
that are regularly entertained in policy discussions focused on 
health and health disparities.
    I will endeavor to make the following four points in my 
testimony: One is that health does not equal healthcare; two is 
that health disparities do not equal healthcare disparities; 
three, health disparities are worsening and are overwhelmingly 
driven by chronic disease; and, four, chronic disease is 
preventable.
    I also hope to touch on some of the false dichotomies 
related to the conflict between universal access and community 
based prevention and the notion of individual responsibility 
versus social responsibility. And, finally, if I have enough 
time--I doubt that I will--I would like to address the issue of 
the immigrant health paradox and the myth that immigrants are 
draining our healthcare system.
    So, to start with, health does not equal heath care. Most 
people who live long and healthy lives in this country--many of 
us represented on this panel and in this room--do so without 
much assistance from the U.S. healthcare system. In fact, a 
reasonable goal of most Americans is to live a life that allows 
us to avoid hospitalization, emergency room visits and even our 
physician's office except for routine, clinical, and 
preventative screening services.
    The best strategy for doing this is to avoid acquiring a 
chronic disease. According to CDC, the medical care costs of 
people with chronic diseases in this country account for 75 
percent of the Nation's $2 trillion medical care costs. Chronic 
diseases are the cause of seven of every ten American deaths, 
and the prevalence of chronic disease in the community is a 
primary driver of the demand for healthcare services.
    As a healthcare program administrator, I live with the 
reality of the so-called 80/20 rule, which refers to the fact 
that 80 percent of healthcare costs are driven by 20 percent of 
the population. Relatively modest shifts in the overall chronic 
disease burden in that 20 percent can have dramatic effects on 
healthcare costs and utilization. Thus, the overall health of a 
community is not primarily shaped by access to healthcare. 
Instead, access to healthcare serves to remediate and repair 
the damage that the healthcare system is presented with as the 
result of the overall prevalence of chronic disease in a 
community.
    Now, get me right here. Healthcare access matters, and this 
is one of the first false dichotomies. To argue that the 
overall community health status is not primarily controlled by 
access to healthcare is not equivalent to arguing that access 
to healthcare plays no role in shaping overall community 
health. We know about the consequences of lacking access to 
healthcare, and I am not going to repeat them here because we 
have many people on this panel and this Committee has heard 
this before. And we know certainly that access to healthcare 
reduces the chronic stress of poverty in many communities. 
Simply by reducing the specter of personal bankruptcy 
associated with catastrophic medical illness, universal access 
to healthcare will ease the chronic stress of being working 
poor in this country. It also reduces job lock, which is the 
fear of leaving your job when you have a pre-existing illness 
due to the fact that you are afraid that you will not be able 
to get insurance in your next job.
    Healthcare disparities do not equal health disparities. 
Healthcare disparities are the result of a healthcare system 
that lacks accountability for health outcomes and lacks 
transparency regarding the selection and application of 
treatment regimes. Therefore, any policy initiatives that serve 
to increase accountability and transparency of the Medicare 
system will create pressure on the healthcare system to reduce 
differential treatment by race/ethnicity.
    A particularly critical accountability and transparency 
measure, and is referenced in the CHAMP Act, is the collection 
of data on race, ethnicity, and primary language of 
beneficiaries. Such data allows health systems researchers and 
healthcare quality improvement practitioners to identify 
systematic biases in provider and system behavior and thereby 
adjust and correct their performances.
    Now, health disparities are differences in health status 
and outcomes that occur largely independent of the health 
system and consequently are much broader in scope and impact 
than healthcare disparities.
    In my county, Alameda County, we have mapped health 
disparities geographically using geographic information systems 
and have demonstrated geographic patterns of disease and death 
distribution that correlate closely with the distribution of 
other important health protective resources such as 
opportunities for employment, recreation, health, high-quality 
education, and living-wage income.
    These strong correlations suggest that health disparities 
are substantially structural in nature and can be ameliorated 
by facilitating better access to proven health protective 
resources and opportunities for low-income communities and 
including rural communities regardless of race but with a 
particular focus on those communities that have a 
disproportionate concentration of African Americans, Native 
Americans, Latinos, and Pacific Islanders. The health status of 
these particular groups is demonstrably worse than other race/
ethnic populations in terms of chronic disease, particularly 
around obesity, diabetes, and portend worsening outcomes for 
the larger population in America. And in many ways these 
populations represent canaries in our coal mine; and the 
vulnerability due to racial discrimination, low income, poor 
education, environmental pollution make these populations more 
prone to the impacts of larger disease-generating social trends 
that will ultimately seep into the larger population.
    I see that my time has run out. I would like to make the 
point and hopefully in questioning we can discuss the issue of 
false dichotomies around individual responsibility versus 
community responsibility and address the myth that immigrants 
are somehow bleeding our healthcare system. That is patently 
false. Immigrants have in many cases in Alameda County and 
elsewhere much lower utilization of healthcare services than 
native-born or American-born populations and relatively good 
health status given the levels of poverty. So I am happy to 
address that issue if it comes up in the questioning.
    Thank you.
    Chairman STARK. Thank you.
    [The prepared statement of Dr. Iton follows:]
        Prepared Statement of Anthony B. Iton, M.D., J.D., MPH,
 Director of Public Health & Health Officer, Alameda County, California
    Good morning Chairman Stark and Members of the Subcommittee on 
Health, thank you for the opportunity to testify today on addressing 
disparities in health and healthcare. My name is Dr. Anthony Iton, 
Director and Health Officer, Alameda County Public Health Department. I 
will keep my comments brief and concise. A copy of my written testimony 
will be submitted for the record. I am a dually board certified 
physician, an attorney and the Director of a large local public health 
department in Northern California. Approximately 11% or 170,000 people 
in my county are uninsured.\1\ Our county runs three public hospitals, 
several outpatient health clinics and funds healthcare services for the 
uninsured at several other community-based health clinics. In addition 
we manage a large clinical mental health and substance abuse program as 
well as providing a broad array of public health and environmental 
health services. The combined cost of these county-provided services is 
about $1 billion dollars per year.
---------------------------------------------------------------------------
    \1\ California Health Interview Survey 2007.
---------------------------------------------------------------------------
    Recently, I had the privilege to participate in the creation of a 
multi-part PBS television documentary entitled Unnatural Causes: Is 
Inequality Making Us Sick. In concert with the national airing of that 
documentary series, my health department released a report on the 
preventable root causes of health disparities entitled Life and Death 
From Unnatural Causes: Health and Social Inequity in Alameda County. My 
testimony is largely based on research and data that appear in both the 
television series and the report as well as upon the experience of 
providing public health and healthcare services to the 1.5 million 
residents of Alameda County.
    The focus of this hearing is healthcare disparities in the Medicare 
system. My particular input will be on the evidence that while access 
to healthcare is a critical contributor to overall health status, the 
healthcare system, by itself, cannot successfully reduce health 
disparities and that unless greater attention is paid to public health 
approaches to reducing health and social inequity, the Medicare system 
will be bankrupted due to the inexorable burden of chronic disease. I 
will also address several false dichotomies and myths that are 
regularly entertained in policy discussions focused on health and 
healthcare disparities. Good policymaking will endeavor to avoid the 
trap of becoming locked into these unhelpful and simplistic dichotomies 
and instead look for opportunities to create mutually reinforcing 
strategies that simultaneously address several of the proximate and 
root causes of health disparities. Preventive policies that address 
root causes tend to be more cost-effective, sustainable, and socially 
just.
    I will endeavor to make the following points in my testimony:

      Health % healthcare. Access to a high quality system of 
affordable healthcare is an important human right and a necessary 
strategy for improving health and quality of life and reducing health 
disparities, but healthcare alone is not sufficient to ``produce'' 
health in populations.
      Health disparities % healthcare disparities. Healthcare 
disparities are a subset of health disparities and can only be reduced 
by increasing accountability and transparency within healthcare 
delivery systems. However, the healthcare system cannot effectively 
eliminate health disparities which are firmly rooted in larger social 
inequities related to the historical legacy of discrimination by race, 
class, gender, disability, and immigration status. These historical and 
present injustices are only remediable by focused social policy 
targeted at increasing opportunity across a broad range of policy 
domains.
      Health disparities are worsening and are overwhelmingly 
driven by chronic disease.
      Chronic disease is preventable.
      Individual responsibility versus community responsibility 
is a false dichotomy.
      The Immigrant Health Paradox and the myth of immigrants 
bleeding our healthcare systems.

    This Committee has certainly heard testimony on numerous occasions 
regarding the need for universal healthcare in this country. I strongly 
support that view and consider universal access to a high quality and 
affordable system of healthcare to be a fundamental human right. 
Everyone of us should feel shame at our failure to achieve this basic 
policy goal. However, universal access to medical care alone will not 
eliminate the profound and worsening health disparities in the U.S. 
because these health disparities are rooted in deeply entrenched social 
inequity. Racial and ethnic health disparities are patterned on 
profound race/ethnic disparities in income, employment, education, and 
other critical social resources.
Health % Healthcare
    Most people who live long and healthy lives in this country do so 
without much assistance from the U.S. healthcare system. In fact, a 
reasonable goal of most Americans is to live a life that allows us to 
avoid hospitalization, emergency room visits, and even our physician's 
office, except for routine clinical preventive services. The best 
strategy for doing this is to avoid acquiring a chronic disease. 
According to the CDC, the medical care costs of people with chronic 
diseases account for more than 75% of the nation's $2 trillion medical 
care costs. Chronic diseases, (primarily heart disease, stroke, cancer, 
and diabetes), are the cause of seven of every 10 Americans deaths. 
Chronic, disabling conditions cause major limitations in activity for 
more than one of every 10 Americans, or 25 million people. The 
prevalence of chronic disease in a community is a primary driver of the 
demand for healthcare services.
    As a healthcare program administrator, I live with the reality of 
the so-called ``80/20 rule '' which refers to the fact that 80% of 
healthcare costs are driven by 20% of the population. Relatively modest 
shifts in the overall chronic disease burden of that 20% of the 
population can have dramatic effects on healthcare costs and 
utilization. In general, our reactive healthcare system is primarily 
designed to mitigate the adverse consequences of chronic disease rather 
than prevent the occurrence of chronic disease in the first place. Thus 
the overall health of a community is not primarily shaped by access to 
healthcare, instead, access to healthcare serves to remediate and 
repair the damage that the healthcare system is presented with as a 
result of the overall prevalence of chronic disease within the 
community.
    However, to argue that overall community health status is not 
primarily controlled by access to healthcare is not equivalent to 
arguing that access to healthcare plays no role in shaping overall 
community health. This is the first false dichotomy that serves to 
distract us from thoughtful policy solutions. Access to high quality 
and prevention focused healthcare is not only a basic human right, but 
this Committee has previously heard testimony from various individuals 
and organizations regarding the overwhelming evidence of the 
consequences of inadequate access to healthcare. These consequences 
include delayed and foregone care, increases in expensive care 
including emergency room visits and preventable hospitalizations, 
decreased quality of life and decreased productivity, and premature 
death.\2\ Above and beyond that, access to healthcare reduces the 
chronic stress of poverty. Simply by reducing the specter of personal 
bankruptcy associated with catastrophic medical illness, universal 
access to healthcare will ease the chronic stress associated with being 
working poor in this country. It will also reduce so-called ``job-
lock'' wherein people with pre-existing illness remain in sub-optimal 
employment in order to maintain health benefits. Access to healthcare 
is therefore necessary but not sufficient to eliminate persistent 
racial/ethnic health disparities.
---------------------------------------------------------------------------
    \2\ Kaiser Family Foundation. The Uninsured: A Primer.
---------------------------------------------------------------------------
Health Disparities % Healthcare Disparities
    Just as health does not equal healthcare, healthcare disparities 
are a subset of health disparities. Healthcare disparities are well-
documented and are the differential outcomes that patients achieve 
after presenting to healthcare facilities. Healthcare disparities are 
the result of a healthcare system that lacks accountability for health 
outcomes and lacks transparency regarding the selection and application 
of treatment regimens. Therefore any policy initiatives that serve to 
increase the accountability and transparency of the Medicare system 
will create pressure on the healthcare system to reduce differential 
treatment by race/ethnicity. A particularly critical accountability and 
transparency measure is the collection of data on race, ethnicity and 
primary language of beneficiaries. Such data allows health systems 
researchers and healthcare quality improvement practitioners to 
identify systematic biases in provider and system behavior and thereby 
adjust and correct their performance.
    Health disparities are differences in health status and outcomes 
that occur largely independent of the healthcare system and 
consequently are much broader in scope and impact than healthcare 
disparities. In Alameda County, we have mapped health disparities 
geographically using geographic information system (GIS) technology and 
have demonstrated geographic patterns of disease and death distribution 
that correlate closely with the distribution of other important health-
protective resources such as opportunities for employment, recreation, 
high quality education, and living wage income. These strong 
correlations suggest that health disparities are substantially 
structural in nature and can be ameliorated by facilitating better 
access to proven health-protective resources and opportunities for low 
income communities regardless of race, but with a particular focus on 
those communities that have a disproportionate concentration of 
African-Americans, Native Americans, some Latinos and Pacific 
Islanders. The health status of these particular groups is demonstrably 
worse than other race/ethnic populations and trends in obesity, 
diabetes and chronic disease portend further worsening of health 
outcomes in these groups. In many ways, these populations are the 
``canaries in the coalmine'' for the rest of the U.S. population. The 
vulnerability due to racial discrimination, past and present, low 
income, poor education, environmental pollution, and geography, make 
these populations more prone to the impacts of larger disease-
generating social trends that will ultimately seep into the larger 
population. There is already some evidence for this phenomenon. CDC has 
predicted for many years now that children born in the year 2000 will 
have a 1 in 3 chance of developing diabetes in their lifetime. If that 
child is African-American or Latino, the odds are 1 in 2. Recently 
published research examining life expectancy for various regions across 
the United States now demonstrates for the first time, declining life 
expectancy in a cluster of counties in the Southeastern and lower mid-
Western part of the U.S.\3\ This unprecedented decline in lifespan can 
largely be attributed to changing chronic disease prevalence. It does 
not bode well for the overall health and productivity of the country.
---------------------------------------------------------------------------
    \3\ The Reversal of Fortunes: Trends in County Mortality and Cross-
County Mortality in the United States. Ezzati, M. et al. PLos Medicine 
April 2008, Volume 5, Issue 4, page 66.
---------------------------------------------------------------------------
Health Disparities are Worsening and are Largely Driven By Chronic 
        Disease Disparities
    Economic studies estimate the forgone economic benefit associated 
with the relatively poor health of less educated populations equates to 
roughly 7.6% of U.S. GDP or approximately 1 trillion dollars.\4\ In 
Alameda County and elsewhere in the U.S., racial/ethnic health 
disparities in premature death, disability, and hospitalization are 
overwhelmingly due to a disproportionate burden of chronic disease in 
certain racial and ethnic populations, most notably, African-Americans, 
Native Americans, and Pacific Islanders. Alameda County Public Health 
Department has just released a report, entitled Life and Death From 
Unnatural Causes\5\, which includes an analysis of over 400,000 death 
certificates in Alameda County over a four decade period that indicates 
that premature death is concentrated in certain geographic hotspots and 
that the disparity in life expectancy between these communities and the 
greater community is on the order of 11-15 years of life and 
increasing. All but about one year of that disparity is attributable to 
higher rates of chronic disease in these hotspot communities. Recent 
national studies examining regional disparities in life expectancy in 
the U.S. suggest that health insurance rates and health disparities are 
not well correlated and that expanding health insurance coverage alone 
would still leave huge disparities.\6\
---------------------------------------------------------------------------
    \4\ Technical Report for Overcoming Obstacles to Health: Report 
from the Robert Wood Johnson Foundation to the Commission to Build a 
Healthier America: Economic Value of Improving the Health of 
Disadvantaged Americans. William Dow, PhD.
    University of California, Berkeley, Robert F. Schoeni, PhD, 
University of Michigan
    \5\ Life and Death From Unnatural Causes: Health and Social 
Inequity in Alameda County. Executive Summary. www.acphd.org.
    \6\ Eight Americas: Investigating Mortality Disparities across 
Races, Counties, and Race-Counties in the United States. Murray, C., et 
al.. PLos Medicine September 2006, Volume 3, Issue 9, page 250.
---------------------------------------------------------------------------
Chronic Disease is Very Amenable to Prevention
    Chronic disease in a population is highly amenable to individual 
and community-level prevention. The bulk of those preventive 
strategies, particularly the community-level strategies, occur outside 
of the healthcare system and are strongly influenced by social and 
economic policies particularly policies shaping land-use, employment, 
transportation, income, and education. California's experience with 
tobacco control is arguably one of the clearest examples of the 
benefits of primary prevention on health status, mortality and 
healthcare costs. Between 1990 and 1998, California saved more than $3 
billion in smoking-related healthcare costs. Through a comprehensive 
and multi-faceted approach, California has been able to reduce the 
prevalence of smoking by 33%. Accelerated declines have been 
demonstrated in heart disease deaths and lung and bronchus cancer 
incidence in California. These reductions in morbidity and mortality 
are substantially greater than in the rest of the United States and 
have been attributed to California's success in reducing smoking 
rates.\7\ Similar prevention benefits could be achieved through 
thoughtful and comprehensive primary prevention strategies targeted at 
diabetes. Approaches that prioritized prevention in those populations 
with the highest incidence of chronic disease would not only be cost-
saving and productivity-enhancing, but they would go a longer way 
towards reducing health disparities, BEFORE people enter the healthcare 
system. In his healthcare reform strategy for California, Governor 
Schwartzenegger recognizes the critical role of community prevention 
and the contribution of the environment, both physical and social, to 
increasing the risk of chronic disease. The Governor's Community 
Makeover Grants follow the basic model of California's globally-
renowned tobacco program by seeding multi-sectoral community 
collaborations to promote physical activity, increase access to healthy 
foods and address the root social and environmental causes of obesity 
and other chronic disease precursors.
---------------------------------------------------------------------------
    \7\ California Tobacco Control Update 2006. California Department 
of Public Health, Tobacco Control Program. Available at: http://
www.cdph.ca.gov/programs/Tobacco/Pages/CTCPPublications.aspx.
---------------------------------------------------------------------------
Individual Responsibility vs. Community Responsibility
    Smoking, consuming excessive alcohol, driving without a seatbelt 
and engaging in risky sexual practices, when informed of the potential 
consequences, are choices that individuals make. Similarly, skydiving, 
race car driving, and competitive skiing are inherently risky 
activities that can have potentially devastating health consequences. 
In health, individual responsibility matters and individuals should be 
held responsible for their choices and behaviors. However, many low 
income populations are compelled by circumstances outside of their 
control to live in neighborhoods with poor housing stock, lack of 
recreational facilities and youth programming, poor schools, inadequate 
transportation, high crime, concentrations of liquor stores and fast 
food outlets, and numerous sources of environmental pollution. All of 
these neighborhood environmental conditions are social consequences of 
poverty in this country. All of these conditions have demonstrable 
health consequences and have been implicated in the generation of 
health disparities. In addition to the unique impact that each of these 
health-injurious conditions has on individual health, the synergistic 
and cumulative effect of these conditions over a lifetime is even more 
profound and enduring. As demonstrated by research portrayed in the PBS 
documentary Unnatural Causes, these neighborhood-level conditions 
contribute directly to a high level of chronic stress among low-income 
communities. The conscious and subconscious desire to relieve chronic 
stress drives the desire for short term gratification such as that 
provided by cigarettes, alcohol and unhealthy eating. In this way 
social conditions constrain individual choices. Any of us subjected to 
the unrelenting stress of being a paycheck away from homelessness, or 
one uninsured hospitalization away from bankruptcy, or one bullet away 
from losing a child would be more likely to smoke, drink to excess or 
indulge in other manners of immediate gratification. Undoubtedly, many 
people growing up and living in these environments choose not to smoke, 
drink to excess or engage in other known health risks, however, the 
constant burden of chronic stress in these communities is substantially 
greater than that of more affluent communities and makes it more likely 
that individuals will succumb to these stressors in low income 
communities. The choices we make are shaped by the choices we have. 
Keeping your child indoors away from the park may well save his life in 
many American neighborhoods, including the one in which I work in 
Oakland, California.
    The social consequences of poverty are greatly influenced by 
policies created by this Congress. In many low-income racially and 
economically segregated neighborhoods, as well as many economically 
deprived rural communities in this country, the social consequences of 
poverty have become more severe. These consequences are not inevitable 
or merely unfortunate, they are squarely within the control of 
policymakers. So the notion of policies supporting individual 
responsibility versus those focused on larger social responsibility is 
another false dichotomy. We need to create social policies and health 
policies that foster greater opportunities for all Americans to partake 
of exercise, healthy eating, as well as reduce the stress of poverty by 
reducing its social consequences. One obvious example is to create 
universal access to a high quality and affordable system of healthcare. 
Other strategies are more complex but eminently achievable and include 
improving high school graduation rates, access to living wage 
employment, and affordable housing. Improvements in all of these non-
health outcomes will improve health outcomes. If we are serious about 
eliminating health disparities and preserving the solvency of the 
Medicare system, we need to begin to recognize these social policies as 
health policies.
The Immigrant Health Paradox
    Immigrants to the U.S. are by and large healthier than American 
born residents. They live longer, have less chronic disease, and use 
less medical resources per capita than American born 
residents.5,8 Over time as they acculturate and become more 
American, they get sicker and acquire more disease and their health 
profile begins to more closely resemble the American health profile. In 
this way, America is not good for your health. It is unfair, 
disingenuous and plainly wrong to lay the blame for the woes of our 
healthcare system at the feet of immigrants.
---------------------------------------------------------------------------
    \8\ Immigrants and Healthcare: Sources of Vulnerability. Derose, 
K.P., et al. Health Affairs 26, no.5, (2007), 1258-1268.
---------------------------------------------------------------------------
    Thank you for this opportunity to testify on the larger context of 
health, healthcare and the root causes of health disparities. I invite 
you to go to the website of Unnatural Causes (www.unnaturalcauses.org) 
for a compelling overview of the role of social inequity in producing 
and maintaining health disparities as well as the description of some 
promising solutions.
    Health Status, Health Insurance, and Healthcare Utilization 
Patterns of Immigrant Black Men. Lucas, J.W., et al. American Journal 
of Public Health. October 2003, Vol. 93, no. 10. page 1740-1747.

                                 

    Chairman STARK. Dr. Satel, who is, if I didn't mention this 
before, the Resident Scholar at the American Enterprise 
Institute.

  STATEMENT OF SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN 
                      ENTERPRISE INSTITUTE

    Dr. SATEL. Thank you, Mr. Chairman and Ranking Member Camp 
and Representatives Jones and Becerra. I appreciate the 
invitation to speak to you today.
    I am a Resident Scholar at AEI, but I am here mainly 
because I am the staff psychiatrist at the Oasis Drug Treatment 
Clinic in Northeast Washington. So I speak to you mainly as a 
clinician.
    I reiterate what we have heard a lot of today that remedies 
must go beyond access to care. Coverage is necessary. No 
question about that. But it is not always sufficient. A good 
many of our patients, for example, are on public insurance. But 
they wait until a health crisis before they get care.
    I saw a patient the other day who the week before had an 
abscess on her hand from IV drug use. This is a methadone 
clinic. She was instructed to get antibiotics from her local 
doc, which she did have, but she didn't, and the next week she 
came back with cellulitis and a fever and had to go to the 
emergency room where she was admitted for IV antibiotics. But 
she was a classic case of someone who had health insurance, 
which is critical, and that it may not be enough.
    So why do patients who have access to healthcare not 
exploit it as much as they could or should? And how can systems 
be more responsive to low-income patients by helping them 
leverage the access that they do have? Three points to consider 
in answering that.
    The first is that a large element in fostering healthcare 
seeking is establishing trust. The second is that, once 
patients have sought care, it is very important they adhere to 
the treatment regimens. And, ultimately, for both chronic 
illness management and effective prevention, it is very 
important that patients think in terms of a longer time horizon 
to help keep their encounters with the healthcare system from 
being driven by one crisis after the next.
    What are some strategies that can help achieve these goals? 
One is to establish continuity of care with the same provider. 
Patients who see the same doctor from visit to visit will have 
the opportunity to establish rapport with him or her, which in 
turn will lead to better adherence with treatment regimens. 
This is very important. In fact, a new study from an economist 
at Columbia University found that increasing compliance could 
reduce the black/white health mortality gap by at least two-
thirds. That is quite dramatic. And rapport, of course, enables 
conscientiousness about self care: exercise, diet, risky 
behaviors, smoking, alcohol and unprotected sex.
    Another important way to achieve the goal of exploiting 
access to care is to expand the average length of the doctor 
visit. As you know, the average encounter is about 15 minutes. 
There is almost no time in that period, especially if it is a 
first visit or if the patient is in some sort of acute 
distress, to also elicit his concerns, needs, values, and 
preferences. These are key, but we need Medicaid codes expanded 
to pay for what we call cognitive and evaluative services 
because there really is no time for meaningful encounters.
    In my clinic, oddly enough, I can spend as much time as 
with patients as I want, but we don't take Medicare or 
Medicaid. We have a very interesting consult pay system for the 
poor and working poor.
    Also, we have to target adherence by recognizing that 
chronic illness is actually quite a chore. Compliance can be 
very difficult. Sociologist Linda Gottfredson put it very well 
when she said ``chronic diseases are like jobs.'' She was 
actually referring to diabetes, although it applies to other 
chronic illnesses. There are duties to perform, glucose 
testing, of course, for one, but it requires a regimen of 
training to implement these tasks, continuously monitor one's 
own physical signs, adjust food, exercise, medications and, as 
someone mentioned, coordinate all the professionals that they 
see: the internist, the surgeon, sadly, the nephrologist 
because the diabetes has progressed to liver failure, the 
nutritionist, and so on.
    Type 2 diabetics in general find it very hard to believe 
that they are truly sick until it is too late to avoid the 
complications. Because if you don't feel sick, you often don't 
act, especially when there are so many pressing daily realities 
in your life. The focus on healthcare will recede into the 
background.
    I see this in my patients all the time, dealing with teen-
age kids gone astray, neighborhood crimes, taking care of 
elderly relatives and, unlike the wealthier, who have their 
share of personal and social problems, too, lack of resources 
to buffer those setbacks.
    Given these realities, I mentioned some of the ways we 
could help patients exploit the access they do have. Some 
others include, and these have been mentioned, outreach through 
black churches, social clubs, work sites, patient navigators--
that can be very important; the idea is to give patients as 
much control as they can--language services, dietary habits.
    There is an article today in the New York Times about a 
Harvard study showing that many physicians, even when they do 
provide counseling, aren't attuned enough to the dietary habits 
and cultural dispositions of their population. And so on.
    So I will sum up by saying access to care is vital, of 
course, but will not alone improve the health of minorities 
low-income people as much as we would like because they are not 
often in positions where they can exploit the care.
    Thank you very much.
    Chairman STARK. Thank you.
    [The prepared statement of Dr. Satel follows:]
       Prepared Statement of Sally Satel, M.D., Resident Scholar,
                     American Enterprise Institute
    Dear Chairman Stark, Representative Camp and Members of the 
Committee. My name is Sally Satel. I am a resident scholar at the 
American Enterprise Institute, lecturer at Yale University School of 
Medicine, and the staff psychiatrist at the Oasis Drug Treatment Clinic 
in Northeast Washington D.C.
    Thank you for the invitation to present my views on racial and 
ethnic minority health status and the key principles upon which 
remedies should be based.
    Let me begin by noting that a number of realities are well-
established.\1\
---------------------------------------------------------------------------
    \1\ For a comprehensive review see Klick J, Satel S. The Health 
Disparities Myth (2006), AEI Press at http://www.aei.org/books/
bookID.847/book--detail.asp.
---------------------------------------------------------------------------
    First, we know that differences in health status exist between 
various ethnic and racial groups, and that there are often 
discrepancies in indicated procedure rates across groups.
    Second, we know that many of the factors linked to these discrepant 
rates (e.g., access to care, geographical differences, good quality 
care) are much more closely tied to socioeconomic (status), than to 
race per se.\2\
---------------------------------------------------------------------------
    \2\ Isaacs SL, Schroeder SA. Class--The Ignored Determinant of the 
Nation's Health, New England Journal of Medicine 351 (2004): 1137--42; 
Kawachi I, Daniels N, Robinson DE. Health Disparities by Race and 
Class: Why Both Matter, Health Affairs 24 (2) (2005): 336.
---------------------------------------------------------------------------
    Third, and most relevant to my comments today, we know that these 
factors do not account for the full extent of discrepancy between 
groups.
    Thus, enhancing access to care and quality of care, though 
essential steps toward improving health status among racial and ethnic 
minorities must be vigorously fortified by other improvements that will 
enable patients to benefit the most from the care they do receive (and 
to need it less frequently and less intensively).
    My remarks today will focus of those additional areas of need. To 
effect these changes, healthcare systems and programs must have 
flexibility to target local needs in creative ways.
Correlates of Health Differentials
Geography
    Geographic residence often explains race-related differences in 
treatment better than even income or education. Because healthcare 
varies a great deal depending on where people live, and because blacks 
are overrepresented in regions of the United States that are burdened 
with poorer health facilities, disparities are destined to be, at least 
in part, a function of residence. Researchers who fail to control for 
location effects of low-income will misdiagnose the underlying causes 
of many racial disparities in health.
Hospital Quality
    An underlying cause of disparities may be that minority patients 
are more likely to receive care in lower-performing hospitals. 
Hospitals that treat greater numbers of minority patients generally 
offer poorer quality service than those that treat fewer minorities. 
Conversely, within hospitals, the quality of care is generally 
comparable between whites and minorities when they are admitted for the 
same reason or receive the same hospital procedure.
Quality of Physician
    National physician survey data indicate that physicians in high-
minority practices depend more on low-paying Medicaid, receive lower 
private insurance reimbursements, and have lower incomes. These 
constrained resources help explain the greater quality-related 
difficulties delivering care--such as coordination of care, ability to 
spend adequate time with patients during office visits, and obtaining 
specialty care--that relate directly to physicians' ability to function 
as their patients' medical home.\3\
---------------------------------------------------------------------------
    \3\ Reschovsky JD, O'Malley AS. Health Affairs (Web Exclusive, 
April 2008), 27(3):222-231.
---------------------------------------------------------------------------
Beyond Access and Quality
    Beyond the obvious need to expand access and enhance quality of 
care, other factors demand attention if health differentials are to be 
narrowed.
    Establish continuity of care with same provider--Patients who see 
the same doctor from visit to visit have the opportunity to establish a 
rapport with him (which, in turn, will lead to better adherence with 
treatment regiment and conscientiousness about self-care).\4\ Yet 
African Americans are more likely than whites to rely on emergency room 
care because they do not have a primary care physician.\5\ Other venues 
of non-continuous care are community clinics and hospitals. (Note that 
having Medicaid does not necessarily correlate with having a regular 
source of care.)
---------------------------------------------------------------------------
    \4\ Halbert C et al. Racial Differences in Trust in Healthcare 
Providers Arch Gen Med 166 (2006):896-901.
    \5\ Oster A, Bindman AB. Emergency department visits for ambulatory 
care sensitive conditions: insights into preventable hospitalizations. 
Med Care 41(2003): 198-207.
---------------------------------------------------------------------------
    The Commonwealth Fund 2006 Healthcare Quality Survey finds that 
when adults have health insurance coverage and a medical home--defined 
as a healthcare setting that provides patients with timely, well-
organized care, and enhanced access to providers--racial and ethnic 
disparities in access and quality are reduced or even eliminated.
    Expand the average length of the doctor visit--One of the most 
effective ways to enhance the doctor-patient relationship is for 
doctors to spend sufficient time with each patient--more than the 
standard fifteen minutes--to elicit patients' concerns, needs, values, 
and preferences. We need to have Medicare codes expanded to pay for 
cognitive, evaluative services--and pay more for them.
    Foster health literacy--A patient's accurate understanding of the 
nature of his illness and the purpose of various therapies is essential 
to self-care and treatment adherence. An important new study from an 
economist at Columbia University documented that differences in patient 
self-management trigger a racial mortality gap even when access and 
treatment for chronic heart failure are equalized. The authors estimate 
that targeting compliance patterns could reduce the black-white 
mortality gap by at least two-thirds.\6\
---------------------------------------------------------------------------
    \6\ Simeonova, E. Doctors, Patients, and the Racial Mortality Gap: 
What Are the Causes? Columbia University, November 2007 at http://
www.columbia.edu/es2085/research/jmpaper.pdf.
---------------------------------------------------------------------------
    But compliance is difficult. Sociologist Linda Gottfredson puts it 
well when she says that ``chronic diseases are like jobs.'' She focuses 
on diabetes but her list of tasks that patients have to perform to 
control and monitor their conditions can be generalized to other 
chronic conditions such as moderate to serious asthma, hypertension, 
renal failure, and chronic heart failure.

      Set of duties to perform



Requires training



Implement appropriate regimen



Continuously monitor physical signs



Diagnose problems in timely manner



Adjust food, exercise, meds in timely and appropriate manner

      Coordinate & communicate with others
      Exercise independent judgment with only occasional 
supervision from medical personnel. Efforts to control the condition 
are often tiring, frustrating, and affects family life
    Most Type 2 diabetics find it hard to believe they are truly sick 
until it is too late to avoid the complications (pain, dysfunctional 
eyesight, infections, etc). This is why following disease prevention 
strategies is even more challenging for those with overwhelming 
personal and family and occupational problems. Health recedes into the 
background, surpassed by more pressing daily realities and stresses.
Common Sense Local Innovations
      Educational modules that prepare and coach patients to 
ask questions and present information about themselves to their doctors 
are promising where implemented.
      Grassroots outreach through black churches, social clubs, 
and worksites
      Patient ``navigators'' to help negotiate the system
      Language services
      Bonuses/incentives to get more good doctors into 
distressed neighborhoods.
      Clinic night hours: a great boon to patients with hourly-
wage employment who risk a loss of income, or even their jobs, by 
taking time off from work for doctors' appointments.
      Active pharmacists who issue reminders, provide education 
to ensure patients grasp what they need to know; hotlines

    A key element here is that these services need to be reimbursed.
Conclusion
    Resolving health differentials between racial and ethnic groups 
depends on improved access to care and quality of care. However, reform 
in those areas alone will not be sufficient. Individuals need to be 
able to exploit the care that is available to them. And the way to help 
them achieve this is to target problems that stem from habits and 
dispositions associated with life lived on the lower reaches of the 
socioeconomic ladder. To tailor interventions most effectively, 
healthcare systems need to have the flexibility to respond to specific 
needs of individual communities.

                                 

    Chairman STARK. Now Dr. Rodriguez, who is Associate 
Professor and Vice Chair at UCLA Department of Family Medicine, 
will inform us. Thank you.

    STATEMENT OF MICHAEL A. RODRIGUEZ, M.D. MPH, ASSOCIATE 
PROFESSOR AND VICE CHAIR OF RESEARCH, UCLA DEPARTMENT OF FAMILY 
               MEDICINE, LOS ANGELES, CALIFORNIA

    Dr. RODRIGUEZ. Chairman Stark and distinguished 
Subcommittee Members, thank you for inviting me to this 
important hearing on health disparities and possible solutions 
to address them.
    I am a researcher, educator, and a practicing family 
physician at UCLA; and the focus of my work is on addressing 
health disparities and evaluating approaches to eliminate them. 
It is a great honor for me to be part of this star-studded 
panel of amazing choir singers, but, as the last singer, I will 
try to keep my song short.
    With minority Americans expected to comprise 50 percent of 
the population by 2050, addressing their health needs is an 
increasingly important public policy goal. Providing culturally 
and linguistically appropriate services has the potential to 
improve health outcomes, increase the efficiency of clinical 
and support staff, and result in greater patient satisfaction. 
A good colleague of mine at Harvard demonstrated through 
research how practice policies to promote cultural competence 
are associated with high-quality care for children with asthma.
    As has been mentioned, it is well established that language 
barriers contribute to health disparities. Approximately 55 
million Americans speak a language other than English at home. 
Half of these individuals report they speak English less than 
very well, making them limited English proficient. More than 10 
million children live in limited English proficiency 
households. And, as was mentioned earlier, an inability to 
communicate with your doctor not only creates a barrier to 
accessing healthcare but undermines trust in the quality of 
medical care that is being received and contributes to these 
disparities in healthcare.
    Patients with language barriers have worse access to 
healthcare, lower rates of physician visits and preventative 
services. Even when patients have access to care, if they have 
language barriers, they have less follow-up care for their 
chronic conditions, decreased comprehension of their diagnosis 
or treatment, decreased satisfaction with care, and increased 
medication complications. Language barriers have been found to 
result in longer hospital stays, more medical errors, and lower 
patient satisfaction.
    Fortunately, the quality of medical care can be improved 
through the use of trained interpreters or provision of care by 
bilingual healthcare providers. They decrease medical clinician 
errors, increase patient comprehension, and improve clinical 
outcomes.
    Unfortunately, as was mentioned, three-quarters of 
physicians use family members as interpreters when working with 
their limited English proficient patients. Barriers to the use 
of interpreters include cost and convenience. The need--there 
is a significant need to develop programs and policies to 
promote the provision of adequate language services to this 
rapidly growing limited English proficient population.
    Research suggests that third-party reimbursement may 
improve the use of trained interpreters and quality of care; 
and an OMB study estimated that the overall cost of providing 
language services would be modest, average $4 more per visit, 
equivalent to 0.5 percent of the average cost per healthcare 
visit, and less, far less, than the cost of the disparities.
    There is a critical need to develop reimbursement policies 
for interpretation. Testing alternative methods of delivering 
linguistically appropriate services will enable us to provide 
the best practices and vastly improve both access to and 
quality of services to beneficiaries with limited English 
proficiency.
    A related issue is that, while the Congress passed this 
Title VI of the Civil Rights Act 1964 to ensure that Federal 
money is not used to support programs or activities that 
discriminate on the basis of race, color, or national origin, 
it is unclear to what extent recipients of Federal funds are 
taking reasonable steps to ensure that patients with limited 
English proficiency have meaningful access to programs and 
activities.
    The Department of Health and Human Services should take 
steps to improve compliance and enforcement of its own Office 
of Minority Health Culturally and Linguistically Appropriate 
Services Standards. To improve quality, you need good policy 
informed by good research and good data. Unfortunately, we lack 
the data. Federal agencies should expand their work on data 
collection. The absence of this timely, reliable, and valid 
data is a limiting factor in measuring the progress of programs 
and status for targeted populations.
    States and health surveys and health facilities should be 
mandated to collect data by race, ethnicity, and primary 
language and conduct interviews and have materials in major 
nonEnglish languages. Providers should also be required to 
monitor selected process and outcome measures by race and 
ethnicity.
    As was mentioned by Dr. Satel, an increasing area that is 
important has to do with processes and organizational responses 
that may contribute to disparities, for example, continuity of 
care which has been found to be low particularly in the 
Medicare beneficiaries, many of whom have multiple chronic 
health conditions. Fortunately, recent research has shown that 
patient populations at risk for health disparities may 
particularly benefit from accessible, coordinated, 
comprehensive care delivered through the patient-centered 
medical home. Therefore, there is a particular need to transfer 
practices serving these populations and increase our efforts in 
this promising area.
    I thank the Committee for inviting me to be here today and 
for its consideration of my testimony. I am grateful for your 
commitment and for your concern for the improvement of the 
health and well-being of all Americans.
    Chairman STARK. Thank you, Doctor.
    [The prepared statement of Dr. Rodriguez follows:]
         Prepared Statement of Michael A. Rodriguez, M.D., MPH,
          Associate Professor and Vice Chair of Research, UCLA,
         Department of Family Medicine, Los Angeles, California
    Chairman Stark and distinguished Subcommittee Members, thank you 
for inviting me to this important hearing on health disparities and 
possible solutions to address them. My name is Michael Rodriguez and I 
am a researcher, educator, and practicing family physician at UCLA and 
community clinics. A primary focus of my work is on addressing health 
disparities and evaluating approaches to eliminate them.
    My testimony today will address three areas: first, I will speak on 
the importance of linguistically and culturally appropriate care; 
second, the need for data collection by race, ethnicity and primary 
language; and finally, the need for payment for language assistance 
services as well as compliance with and enforcement of national 
standards on culturally
BACKGROUND
    A large body of literature has documented significant racial, 
ethnic and language disparities in health and healthcare. Racial and 
ethnic minorities have higher rates of disease, disability, and death 
and tend to receive a lower quality of healthcare than nonminorities, 
even when insurance status and income are taken into account. The fact 
that racial/ethnic minorities in this country receive poorer quality 
healthcare is undeniable and attributable to a range of patient, 
clinician, practice, healthcare system, community and social factors. 
The Institute of Medicine ``Unequal Treatment'' report provides 
guidance for why and how we should address this issue and highlights 
how eliminating racial/ethnic disparities in healthcare is an integral 
part of improving the quality of our healthcare system, and the 
healthcare of all Americans.
    Many researchers and policy makers view racial and ethnic 
healthcare disparities through the lens of quality improvement. 
Improving quality through the components of patient safety, timely 
response, and evidence-based, patient-centered care provides a 
framework for eliminating disparities. Meeting the needs of the patient 
population should be the focus of our efforts. As physicians we have a 
professional and moral obligation to deliver the best possible quality 
of care to everyone we see.
    With minority Americans expected to comprise 50% of the population 
by 2050, addressing their health needs is an increasingly important 
public policy goal. Providing culturally and linguistically appropriate 
services has the potential to improve health outcomes, increase the 
efficiency of clinical and support staff and result in greater patient 
satisfaction. Making sure that the healthcare provided to this diverse 
population takes into account the linguistic and cultural needs is a 
priority for health systems and policy makers. As such, a growing body 
of laws and regulations seek to ensure that health systems respond to 
these linguistic and cultural needs. Recent research by Lieu at Harvard 
demonstrates how practice-site policies to promote cultural competence 
are associated with higher quality care for children with asthma.
    Because culture and language are vital factors in how healthcare 
services are delivered and received, it is important that healthcare 
professionals embrace the principles of cultural and linguistically 
appropriate care. Cultural Competency Curriculum are being developed to 
equip clinicians with the cultural and linguistic competencies that 
will enable them to better treat the increasingly diverse U.S. 
population.
DISPARITIES DUE TO LANGUAGE BARRIERS
    It is well established that Language barriers contribute to health 
disparities for limited English proficient (LEP) patients. 
Approximately 55 million Americans speak a language other than English 
at home. This is equivalent to one in five people in the United States. 
Half of these individuals report they speak English less than ``very 
well'' and these individuals are considered to be LEP. More than 10 
million children live in have limited English proficiency households. 
An inability to communicate with your doctor not only creates a barrier 
to accessing healthcare but also undermines trust in the quality of 
medical care received and contributes to disparities in healthcare.
    Patients with language barriers have worse access to care and rate 
their healthcare worse compared to English speakers, have less access 
to a usual source of care, lower rates of physician visits and 
preventive services. Even when patients have access to care if they 
have language barriers they have less follow up care for chronic 
conditions, decreased comprehension of their diagnosis or treatment, 
decreased satisfaction with care and increased medication 
complications. Language barriers have been found to result in longer 
hospital stays, more medical errors and lower patient satisfaction. 
Children in non-English primary language households also experience 
worse outcomes. These children are more likely to be poor, overweight, 
have suboptimal health but have higher risk of impaired access to 
health.
    Consider the following clinical scenario: An Asian speaking mother 
brings her ill baby to an emergency room and cannot communicate with 
the staff. The baby has a fever and is sent home with medicine for the 
fever. Another Asian speaking mother brings her ill baby with similar 
symptoms to an emergency room with Asian-speaking staff and the baby is 
admitted with a diagnosis of appendicitis, is observed with worsening 
abdominal guarding and has emergent surgery and her life is saved.
    Title VI of the Civil rights act of 1964 mandates that healthcare 
providers receiving federal funds provide ``meaningful access to their 
programs and activities by LEP persons'' without cost to the patient. 
Published reviews suggest that the quality of medical care is improved 
through use of trained interpreters or provision of care by bilingual 
healthcare providers. They decrease medication errors, increase patient 
comprehension, and improve clinical outcomes. Three quarters of 
physicians use family members as interpreters and less than half of 
physicians use trained interpreters when working with their LEP 
patients. Barriers to the use of trained interpreters include cost, 
inconvenience, limited availability of trained interpreters. Given the 
association of language barriers and compromised healthcare quality and 
safety, there is a need to develop programs and policies to promote the 
provision of adequate language services to the rapidly growing 
population of LEP families.
    Research suggests that third party reimbursement may improve use of 
trained interpreters and quality of care and the overall cost of 
providing language services may be modest. The Office of Management and 
Budget estimated in 2002 that the cost of interpreter services for LEP 
persons, when averaged over all types of visits, would average $4.04 
more per visit, equivalent to 0.5% of the average cost per healthcare 
visit and less than the cost of disparities.
LANGUAGE SOLUTIONS
    Due to the barriers to using trained interpreters, we need to 
develop and evaluate programs that will improve the medical delivery 
systems of the future. Interpreter services should be developed for 
bilingual staff, bilingual providers as well consultant interpreters 
with certification and training programs. Spanish and other language 
training for clinicians (including CME programs) and for medical 
students should be supported significantly in targeted markets. There 
is a critical need to develop reimbursement policies for these and new 
interpretation technologies that are affordable, especially through 
Medicare and Medicaid.
    Language barriers place LEP patients at a disadvantage that can be 
overcome by providing better linguistic access. Provision of 
interpreter services or direct access to a provider can reduce 
disparities in care for LEP patients. Although recipients of federal 
funds are required to offer language services, Medicare does not 
reimburse for these services. Testing alternative methods of delivering 
culturally and linguistically appropriate services will enable Medicare 
to apply best practices and vastly improve both access to and quality 
of services to beneficiaries with limited English proficiency.
    While congress passed Title VI of the Civil Rights Act of 1964 to 
ensure that federal money is not used to support programs or activities 
that discriminate on the basis of race, color, or national origin, it 
is unclear to what extent recipients of federal funds are taking 
reasonable steps to ensure that persons with limited English 
proficiency have meaningful access to programs and activities. The 
Department of Health and Human Services should take steps to improve 
compliance and enforcement to its own Office of Minority Health 
Culturally and Linguistically Appropriate Services (CLAS) Standards.
USING DATA COLLECTION TO DRIVE QUALITY
    To improve quality, you need good policy informed by good research 
based on good data. Federal agencies should expand their work on data 
collection and disparities research. Without new knowledge with 
community-based research, we may never advance beyond the disparities 
that now exist in the healthcare system. Lack of data places policy 
makers at risk of making inappropriate decisions that reflect a lack of 
understanding of the mechanisms driving the increased burden of disease 
and death as well and its impact. The absence of timely, reliable, 
valid, and appropriate data is often a limiting factor in measuring 
progress of programs and status of the targeted population. States and 
health surveys and health facilities should be mandated to collect data 
by race and ethnicity and language use and conduct interviews and have 
materials in major non-English languages in order to develop a quality 
healthcare system.
    At a minimum, hospitals, health plans, and other providers should 
be asked to maintain data on patients' race and ethnicity. Healthcare 
organizations could also be required to provide training for their 
staff in the delivery of culturally and linguistically appropriate 
services. Finally, providers could be required to monitor selected 
process and outcome measures by race and ethnicity. CMS can encourage 
accrediting organizations to adopt such standards voluntarily, or it 
can strengthen its own requirements. This will help to determine the 
extent to which disparities exist. Collecting such data will help CMS 
to establish baseline information about racial and ethnic disparities 
within Medicare which will assist in the development of interventions 
to address disparities and measure progress toward that goal.
A MEDICAL HOME
    An increasing area of research to address disparities includes 
examining differences in care processs and organizational responses 
that may contribute to disparities. For example, continuity of care has 
been found to be quite low, particularly for Medicare Beneficiaries--
many of whom have multiple chronic health conditions that benefit from 
having a primary care physician. One Commonwealth study found that 35% 
of Medicare beneficiaries' visits each year were with their assigned 
physicians, and a third of beneficiaries changed their assigned 
physician from year to year. If elderly people with multiple illnesses 
cannot receive good care, other healthcare reforms may have less 
impact.
    Recent research has shown that patient populations at risk for 
health disparities may particularly benefit from the accessible, 
coordinated, comprehensive care delivered through the patient-centered 
medical home; therefore there is a particular need to transform 
practices serving these populations. While some of these medical home 
concepts have already been applied in the U.S., they are often in large 
pre-paid group practices or academic medical centers. Therefore a focus 
on recruiting smaller physician practices where much of the care occurs 
for Medicare beneficiaries is needed.
CONCLUSION
    I thank the Committee for inviting me to be here today and for its 
consideration of my testimony. I am grateful for your commitment and 
for your concern for the improvement of the health and wellbeing of all 
Americans.
REFERENCES
    Office of Management and Budget, White House: ``Assessment of the 
Total Benefits and Costs of Implementing Executive Order 13166: 
Improving Access to Services for Persons with Limited English 
Proficiency.'' HHS Office of Civil Rights, Guidance on Limited English 
Proficiency.
    Institute of Medicine, Unequal Treatment: Confronting Racial and 
Ethnic Disparities in Healthcare (Washington, D.C.: National Academies 
Press, 2003).
    P.B. Bach and others, ``Racial Differences in the Treatment of 
Early-Stage Lung Cancer,'' New England Journal of Medicine, vol. 341, 
no. 16 (1999).
    Tracy A. Lieu, Jonathan A. Finkelstein, Paula Lozano, Angela M. 
Capra, Felicia W. Chi, Nancy Jensvold, Charles P. Quesenberry and 
Harold J. Farber. Cultural Competence Policies and Other Predictors of 
Asthma Care Quality for Medicaid-Insured Children. Pediatrics 
2004;114;e102-e110

                                 

    Chairman STARK. I will call on Mr. Becerra and see if he 
would like to inquire.
    Mr. BECERRA. Thank you, Mr. Chairman.
    Welcome to you all. Thank you for your life's work and 
certainly for your testimony today.
    A personal greeting to an esteemed physician and good 
friend, Dr. Rodriguez from UCLA.
    And, Dr. Jang, I suspect you are like me, where my folks 
also hoped that I would be a medical doctor and I sometimes 
claim to be that doctor of law. If that doesn't satisfy them, 
at least I did the next best thing. I married into the 
profession. So, hopefully, you are close.
    I want to just run a few things by all of you to see if you 
might have a chance to comment.
    In the House bill that passed last year that dealt with 
Medicare and children's healthcare, the SCHIP program, we did a 
number of things. I want to thank the chairman right now for 
the work that he did in working with my staff, his staff and my 
staff, working to include a number of provisions to deal with 
these particular issues.
    In the House-passed bill, the Children's Health and 
Medicare Protection Act, the CHAMP Act, we included an 
Inspector General study within HHS OIG, study to examine 
whether the culturally and linguistically appropriate services, 
the CLAS services, required by law are being enforced. We also 
included a demonstration project on outreach to previously 
uninsured Medicare beneficiaries. And just recently the Senate, 
which introduced its similar legislation on Medicare, included 
those two provisions as well in its bill, which is good.
    Unfortunately, the Senate bill that was just recently 
introduced did include a number of other provisions which 
Chairman Stark and I worked very hard to include in the CHAMP 
Act which did pass the House, which include a provision to 
require the collection of ethnicity data for the Medicare fee-
for-service program.
    And I mention this because, Dr. Jang, I think you 
mentioned--in your testimony, you cited the Dartmouth Atlas 
Project, which shows that real disparities between some of the 
care that African Americans receive and whites. Unfortunately, 
because Medicare relies on its administrative data to determine 
race and ethnicity, if you think about it, that administrative 
data is dependent on SSA, the Social Security Administration, 
the SS-5 form. Well, Medicare beneficiaries today are 65 and 
over. That means they certainly applied well before 1980 for 
their Social Security number, which means back in those days 
the only demographic that we took into account was either white 
or black.
    So that study, which pointed out some major disparities for 
African Americans, could tell us nothing for Asian Americans 
and Latinos and Native Americans because they were based on 
these previous applications for a Social Security card and 
number. Those different ethnicities and populations had to be 
categorized as either ``other'' or ``unknown.'' So I guess a 
lot of folks in this chamber, me included, would all be either 
``other'' or ``unknowns'' when it comes to Medicare's ability 
to track important data on disparity.
    We put in the CHAMP Act, with the chairman's help, the 
provision to require the collection of ethnicity data for 
Medicare fee-for-service programs. Unfortunately, the Senate 
has not included that.
    We also included in the CHAMP Act a provision which would 
provide funding for a demonstration project to provide paid 
language services to Medicare beneficiaries, to Dr. Rodriguez's 
point. Medicare providers say, well, it is really tough, 
especially with the cuts that we are seeing these days in 
Medicare reimbursement, to actually now increase fee-for-
services by providing translation by interpreter services. This 
was a provision that would help fund that for a third party. 
That, unfortunately, was not included in the Senate bill 
recently introduced.
    Another provision was a provision that required the 
Institute of Medicine to report on the impact on Medicare 
beneficiaries who need but do not get language access services. 
That provision was not included in the Senate. It is in the 
CHAMP Act.
    And, finally, we include in the CHAMP Act a provision that 
would require a study on the impact of managed care plans on 
minority beneficiaries, because there is a great deal of talk 
about whether managed care is good or bad for populations that 
suffer from disparities.

RPTS MCKENZIE

DCMN HOFSTAD

    Mr. BECERRA. And that provision, which did get included in 
the CHAMP Act, was excluded in the Senate's bill.
    And so I guess my question to you is, I think while the 
House has done some remarkable work in trying to address the 
disparities issue, are you at all doing any work with our 
Senate colleagues to try to see if they can do a better job of 
including these very modest proposals--because cost-wise, they 
are very modest--these very modest proposal to make sure that 
they are included in the Senate Medicare bill that is working 
its way through the Senate?
    And I know my time has expired, but if anyone has any 
particular comments, Chairman, I would love to see if they 
might have a chance. And Dr. Blanton might be the person who 
probably works on this most.
    Ms. LILLIE-BLANTON. Well, actually, I want to agree with 
you that we need to do more data collection by race, by 
ethnicity, by language services. Our population is changing 
dramatically, and without the information to help us understand 
the quality of care these people are getting, the access that 
they get, it is impossible for us to know how much progress we 
are making. So I just want to say that is critically important.
    You also raised concerns about research and analysis. And I 
think what we have to realize is that when we collect the data, 
we have to analyze the data and we have to report on the data. 
And unless we do both of the latter two, you will have data 
collected that is just sitting there. And so it is important 
for us to do further analysis to better understand how the 
information that we have collected is being used.
    Demonstration projects is one way of learning more, but 
putting in place systems that can routinely monitor and assess 
and evaluate is a way to structurally assure that we know what 
is happening over time in our population. So in addition to 
demonstration projects, the systematic analysis and assessment 
is what is really needed.
    We have moved to a whole new system of coverage and care 
delivery with our managed care plans. And putting in place the 
mechanisms for us to know how our beneficiaries in managed care 
are faring in relation to the care they are receiving is just 
as important as systems in place to know how are beneficiaries 
in fee-for-service.
    So I actually just want to agree with you and with the 
provisions. But our organization is not one that actually is 
involved in advocating and working with legislation, so we are 
not involved directly. But there are others here on this body 
who are, so they may want to speak to that issue.
    Ms. JANG. I can speak to that, Congressman.
    The Asian Pacific Islander American Health Forum is working 
in coalition with a number of minority health organizations 
under the auspices of ``Out of Many, One.'' And we have been 
working together with the American Heart Association to 
advocate for the inclusion in the Senate's Medicare bill of a 
provision that gives the Secretary of HHS the authority to 
mandate the collection of data on race, ethnicity and gender as 
part of the quality measures that Medicare health plans have to 
report on.
    So we see that as a good step, giving the HHS--because we 
do think that they do have the administrative authority to do 
that. So we are hopeful that it has been included in the Senate 
Medicare bill.
    Chairman STARK. Thank you.
    Mr. BECERRA. Thanks, Mr. Chairman.
    Chairman STARK. Mr. Camp, would you like to inquire?
    Mr. CAMP. Thank you, Mr. Chairman.
    And, Dr. Blanton, I agree with you on data collection and 
analysis. And you may have heard my comment to the other panel. 
We often get requests to act on data that is 3 and 4 years out 
of date. And you are correct, there is a dramatically changing 
healthcare environment out there, and we often don't get that. 
So I hope we can maybe improve that.
    I had a question for Dr. Akhter. You mentioned about the 
importance of coordinating care and the difference between 
acute and chronic care, and that many seniors today have to 
deal with multiple diseases, go to different facilities, have 
different providers, doctors. And you say that this is 
especially true of those--and I am quoting from your 
testimony--of those seniors from minority populations, and 
exacerbates rather than reduces disparities.
    And we have about 8 million seniors, including about 1 
million minorities, who have chosen to enroll in Medicare 
Advantage that coordinates their care and helps manage their 
chronic diseases and illnesses. Do you believe this type of 
coordination would be helpful to greater minority populations 
and especially those with chronic conditions?
    Dr. AKHTER. Thank you, Mr. Camp. This is a very important 
question.
    Certainly, coordination will help, but we also need to 
collect data to monitor to see what the effect is going to be. 
And, you know, data collection is a very important part of us 
knowing what gets done, what gets measured that gets done. And 
if we have a measuring tool that measures whether this 
coordination is helping or whether we are just simply not doing 
the coordination or doing the coordination to provide less 
care, then it would not be very beneficial. So I----
    Mr. CAMP. Do you think Medicare fee-for-service, which does 
not coordinate care, will ever be able to resolve these 
disparities that you mentioned are exacerbated by----
    Dr. AKHTER. If we continue in this way, the way we have 
been doing business in the past, it certainly will not. But I 
think, again, coordination is important, but also monitoring is 
important, so that we all have a transparency in the system 
where we can all see what is being actually done on the ground.
    Mr. CAMP. Thank you.
    And I want to thank you all for your testimony today.
    Dr. Satel, we have heard about the discrepancies that exist 
in health outcomes in certain populations. And if two people 
with the identical diagnosis but different races are admitted 
to the same hospital for treatment, what has research told us 
about their treatment and their recovery?
    Dr. SATEL. Actually, the research is--some studies will 
show that there are differences in the receipt of certain 
services. Cardiac care has been one of the most incisively 
examined ones. What is interesting, though, is the fact that 
many of the studies, even though they saw a discrepancy in the 
rate with which African Americans--most of the early work has 
been done, really, black-white comparisons. Even though that 
the African Americans were less likely to receive certain 
procedures, mortality rates were similar. Not all studies found 
that, but a lot of them did. That didn't say anything about 
morbidity rates, but it said that mortality rates were--some of 
them found either equal or actually lower for the African 
Americans.
    But the moral of that story is, as others have suggested, 
is that we have to look as carefully at outcomes as we do at 
the, you know, counting up of procedures. It is important to 
know how often procedures are administered. We also have to 
wonder are, perhaps, white people being overtreated because 
they tend to be more litigious, and malpractice considerations, 
that is something to think of.
    It also raises another point that I would love to see more 
ethnographic research. When we do see discrepancies, we are 
left with trying to figure out what they are about. And often 
they indicate something very subtle that we really can't pick 
up from looking at databases in retrospect. We really want to 
know, what did the physician tell the patient? What did the 
patient truly understand? What were the preferences of the 
patient? These kinds of considerations that are very, very 
fine-tuned and don't emerge from big databases and really 
does--I would love to see NIH fund that kind of work.
    It is basically sociology, but that can be done in an 
empirical and standardized way. And I think that would be a big 
contribution to understanding the fine-grained explanations for 
some of these differences.
    Mr. CAMP. All right. Thank you.
    And I guess to the extent we have received some testimony 
on private-sector initiatives in the effort to eliminate 
healthcare disparities, there are a number of those that are 
taking place throughout the country as well.
    But thank you all. I see my time has expired.
    Chairman STARK. Mrs. Tubbs Jones, would you----
    Mrs. JONES. Mr. Chairman, thank you very much.
    And I want to thank all the witnesses for coming to this 
historic hearing, focused on racial and ethnic disparities in 
healthcare. I wish I had hours, and I don't. But there are two 
or three things I do want to focus on.
    And I want to ask you, Dr. Satel, do you know who Linda 
Gottfredson is?
    Dr. SATEL. A sociologist at the University of Delaware.
    Mrs. JONES. And do you give credence to her research and 
her comments?
    Dr. SATEL. Oh, on this, as far as the way she framed the, 
sort of, the comparison of having a chronic illness to almost 
having a job?
    Mrs. JONES. No, not that one. I have another one for you.
    Dr. SATEL. Oh, I know what you are referring to.
    Mrs. JONES. You know what I am referring to?
    Dr. SATEL. I am pretty sure I do.
    Mrs. JONES. Tell me.
    Dr. SATEL. I suspect--well, she has done a lot of work on 
IQ and race.
    Mrs. JONES. And what has her work on IQ and race shown?
    Dr. SATEL. Frankly, I didn't--that is not what I looked at. 
I looked at the work she has been doing on education, diabetes 
education and health literacy.
    Mrs. JONES. Well, when you cite someone, you live with what 
you like what they say and what you don't like about what they 
say, don't you?
    Dr. SATEL. Not necessarily.
    Mrs. JONES. You give credence to them as--anyway, let me 
not argue. Let me quote her for the record so that it is clear 
that everybody understands who you rely upon.
    Quote, ``Health scientists have noted that differences in 
an individual's cognitive abilities may explain why some 
patients receive better care than others. This theory suggests 
that the variation of effective treatments may result from an 
inner quality of reasoning capabilities among patients. 
Patients with lower general reasoning abilities are less likely 
to seek preventive care, to know signs and symptoms of disease, 
and to adhere to treatment regimes.''
    I personally, you know, think it is, like, code words. And 
we go back to the problem with discrimination among racial and 
ethnic minorities when we start talking about their cognitive 
abilities.
    I am not looking for an answer from you. I am merely 
placing into the record a person whose statements you rely upon 
to make your point.
    I want to raise with you, however--you are a psychiatrist; 
is that correct?
    Dr. SATEL. Yes.
    Mrs. JONES. Why haven't you talked at all about the issue 
about psychiatry, A very necessary part of health treatment and 
the disparities that exist among racial and ethnic minorities 
having access to psychiatry, as part of your presentation 
today?
    Mrs. JONES. Right. Well, that is actually a place where--
when I mentioned the ethnographic approach, that is where it is 
so important. Because there are so many cultural----
    Mrs. JONES. No, I am asking you, why didn't you use that as 
part of your testimony here today, to talk about that very 
issue that you specialize in, psychiatry?
    Dr. SATEL. Because I happen to--I just decided to take a 
broader approach. But I could talk about psychiatry.
    Mrs. JONES. Thank you.
    Let me go on to someone else.
    Dr. Blanton, first of all, good morning--good afternoon. It 
is afternoon now.
    Ms. LILLIE-BLANTON. Good afternoon.
    Mrs. JONES. If there was one thing you could do, one, what 
would you--let me stop for a moment.
    To people who are listening to this hearing out in the 
world and have not had a background or experience in healthcare 
and would like to provide some testimony that would be of 
assistance to the Committee, they gave me a convoluted way of 
you doing this, which is go to house.gov, link to the Committee 
on Ways and Means, link to this hearing, and send it in. But an 
easier way is to send it to me at [email protected]. That is 
[email protected]. Because I know there are others who would 
want to have an opportunity to add something to our discussion. 
And I am interested and I am sure the Committee is interested 
in having additional information.
    Back to you, Dr. Blanton.
    Ms. LILLIE-BLANTON. You said if there was one thing I could 
do?
    Mrs. JONES. One piece of advice you would give us as 
Members of this Health Committee.
    Ms. LILLIE-BLANTON. If there was only one thing that could 
be done, I would say we need to expand sources of coverage or 
reduce the number of uninsured.
    While we know insurance coverage is not the only thing that 
makes a difference, we know that those who lack coverage face 
financial barriers to care that affect not only their health 
status but affect their ability to function in society, you 
know, in terms of--you know, financially function in society, 
with their jobs, with their families.
    And so that would be the one thing, if there was only one 
advice.
    Mrs. JONES. Dr. Iton, can you for a moment address the 
issue that there is some myth about healthcare disparities or 
access to healthcare among races?
    Dr. ITON. The data is overwhelming. There is absolutely no 
credible argument that health disparities and healthcare 
disparities don't exist. My argument has been that the linchpin 
to understanding health and healthcare disparities is 
understanding chronic disease and the distribution of chronic 
disease throughout populations.
    And I agree that the first thing we have to do is to get 
everybody into a universal system of high-quality, affordable 
healthcare. That is critical, and it is a matter of human 
rights.
    But the second thing is, we are not going to be able to 
manage healthcare into the 21st century unless we get a handle 
on chronic disease, because that will bankrupt our systems. And 
we can do that. There is evidence of that. California has done 
it around tobacco and has shown a substantial decrease in 
tobacco-related heart disease, lung cancer, bronchus cancer, 
and a decrease of about $3 billion in healthcare costs between 
1990 and 1998. California has set an example for this. Other 
States can do it. And we need to focus on obesity and diabetes 
next.
    Mrs. JONES. I thank all of you.
    I am way out of time, Mr. Chairman. I thank you for this 
extra minute or 2 for your testimony.
    We, as Members of Congress, you know, we are viewed as 
politicians. So when I start talking about healthcare 
disparities, ``Well, you don't have any background; what do you 
know?'' So I am glad to be able to have someone with some 
background and some experience say and--what is the word--
second or testify to the fact that there are healthcare 
disparities in America and how we need to address it.
    Mr. Chairman, I thank you so much for the opportunity.
    Chairman STARK. Thank you.
    Mr. Johnson, would you like to inquire?
    Mr. JOHNSON. Thank you, Mr. Chairman.
    Ms. Blanton, you kind of got leaned on. I am going to ask 
you, you have heard from other witnesses, or we have, today 
that universal access to health coverage is important. However, 
your testimony cites research that found health disparities 
exist among different demographics, even in the Medicare 
program.
    Is that what you said?
    Ms. LILLIE-BLANTON. Yes, that is correct.
    Mr. JOHNSON. Could you please elaborate on your findings? 
Since Medicare is a government-run entitlement program 
universally accessible to individuals in this country age 65 
and over or those otherwise disabled, that ought to give us 
some insight. If you could discuss it, I would appreciate it.
    Ms. LILLIE-BLANTON. Well, first of all, I think many of our 
panelists have already talked about some of the other factors 
that determine the access and the quality of care that people 
have.
    One, very importantly, is the availability of health 
resources, whether it is physicians, whether it is other 
provider groups. So if you are living in a neighborhood where 
you don't have access to the providers or you don't have access 
to the specialists, then you may not get the same care that 
someone else has. If you are living in a community where 
language barriers become an issue, you may not get the same 
care that someone else----
    Mr. JOHNSON. Well, I will tell you what, I just ran into a 
situation in our hometown, which is full of hospitals, that 
there were two of them that didn't--closer to us that didn't 
have their emergency rooms open. And I don't know if that is 
happening across the country or not. Are you aware of that 
situation?
    Ms. LILLIE-BLANTON. Well, I have not tracked whether or not 
it has occurred at any increasing frequency, but it is a 
reality. It is a fact that some hospitals are closing their 
emergency rooms. And part of that has to do with emergent 
patients, emergency patients who are uninsured and adding to 
the costs. So it is a financial issue, but it is still an issue 
that becomes a barrier to care for people, particularly in 
emergency situations.
    So I would say that both availability of providers becomes 
a big issue and language becomes an issue. But there are still 
other factors that affect disparities in care. And sometimes 
the issue we really have a hard time understanding are just how 
personal biases about who is deserving and more deserving or 
less deserving of care for whatever reason. Sometimes it is 
racial discrimination, sometimes it is discrimination because 
of the condition that they are facing. Patients with mental 
health problems, patients with other kinds of substance abuse 
problems may have different access to care. So----
    Mr. JOHNSON. Well, are you saying they categorize people 
who are over 65, even though they are all on the same program?
    Ms. LILLIE-BLANTON. Let me say that there are very subtle 
ways where a bias about a patient may enter into the care 
delivery system. And so it may not be overt biases. It could 
just be judgments about the individual.
    But in the research that has been done to look at the 
factors, there probably is a broader systemic factors, such as 
the availability of providers, that play a larger role. But you 
still can't discount the interaction between a patient and a 
provider as one of the factors that influences the quality of 
care and their access to care.
    Mr. JOHNSON. Thank you very much.
    Thank you, Mr. Chairman. No further questions.
    Chairman STARK. Well, the answer that I think Dr. Blanton 
gave, as to what is the one thing we could do to begin the 
process of reducing disparities, would be to do in whatever way 
we are able to expand coverage to people that don't have 
coverage.
    I have always been under the assumption that to not have a 
payment plan pretty much means, in this country, you are denied 
access to medical care. You may be able to get it at the 
eleventh hour in the emergency ward, but I think that I 
wouldn't get much argument to say that if you don't have a 
payment plan, you are not in the game.
    I wanted to ask Dr. Iton, it has been discussed here, and 
both referred to obliquely and directly, what I am going to 
call the difference between race and class. My race is obvious. 
I hope my class isn't that obvious.
    But, Dr. Iton, what is more important in determining the 
health of a senior citizen, their economic class, their 
education level, where they live, or their race?
    Dr. ITON. Well, I think that is one of those either/ors 
that is sort of impossible to address, particularly with the 
limited data we have on class.
    We have done pretty extensive analyses of health 
disparities according to race and income, you know, income 
being sort of a crude estimate of socioeconomic status. And 
when you stratify populations across incomes, you see very 
clear correlations between length of life and income. The 
poorer you are, the shorter your life is. The poorer you are, 
the more chronic disease you are saddled with.
    When you substratify that by race, you see an additional 
burden imposed upon that stratification. That is pure race. In 
other words, that wealthy African Americans have a higher rate 
of chronic disease and health disparities than wealthy whites. 
And these kinds of associations suggest that race and class 
play an important role in mediating health disparities.
    But one thing I would want to point out, though, is that 
immigrants seem to fly against that general rule. And we find 
that immigrants tend to, regardless of class, tend to have 
better health outcomes than nonimmigrants. And that is, I 
think, an important thing to try to understand, because there 
are variables here that will play an important role in 
designing how we approach the reduction and elimination of a 
heavy burden of chronic disease in low-income populations.
    I can expand on that further, but I just wanted to raise 
that issue, because sometimes we lump things together in ways 
that don't help the discussion. And understanding, for 
instance, in California, how low-income Latino immigrants have 
longer life expectancies than high-income whites is something 
very important to understand in designing public health and 
health policy.
    Chairman STARK. Do you want to----
    Mr. BECERRA. Sure.
    Chairman STARK. Why don't I yield to my distinguished 
friend.
    Mr. BECERRA. Mr. Chairman, thank you.
    Dr. Iton, it is a prescient observation that few know. But 
the disturbing part of that is, if you extend the observation a 
little further, you find that the longer the immigrant has been 
here, or with the next generation of the children that followed 
that first-generation immigrant, the outcomes start to mimic or 
reflect those of the native-born population. So if you are 
minority and poor and you are the son or daughter or the 
granddaughter or grandson of an immigrant, then chances are you 
are going to reflect more your peers who are native-born when 
it comes to health outcomes than you do your parents, your 
grandparents, who were poor but in better health.
    So that is an unfortunate thing. It sort of flies contrary 
to what you think, the longer you are here in America, the 
worse your health gets.
    Dr. ITON. Yes. We sometimes say that America is not good 
for your health.
    Mr. BECERRA. Yes, exactly.
    Dr. ITON. And the evidence suggests that. And that is 
important to understand, as well. Why does that happen? What is 
it about becoming less of an immigrant and more of an American 
that inures toward health behaviors and----
    Mr. BECERRA. I think it is the lifestyle.
    Dr. ITON. Exactly.
    Mr. BECERRA. More smoking, more drinking, less exercise. 
The more affluent you become, the less you need to do physical 
labor. And you find a lot of these immigrants working very long 
hours, don't have the money or the time to go out and drink or 
smoke too much. And so it is--the fact that you have to live a 
modest way keeps you pretty healthy.
    And I suspect if you were in a rural area--I suspect if Mr. 
Moran, Congressman Moran, were still here, he would probably 
tell us that he finds that in a lot of parts of Kansas, a lot 
of those folks who are still in rural America probably have 
pretty decent health because they have to work so hard as well.
    Dr. ITON. Well, we spend a lot of time in public health 
trying to actually distill out what it is about that immigrant 
health behaviors that we can actually spread to the larger 
population, because we think immigrants teach us a lot about 
health-protective behaviors.
    Mr. BECERRA. Maybe we can tackle that immigration political 
issue first.
    Chairman STARK. I was going to ask Dr. Rodriguez to explain 
to me why Los Angeles hasn't gone bankrupt, which is--the one 
thing I have to say, Doctor, we have a marvelously diverse 
county, as the doctor knows. I am now a minority in the county. 
And we have a very liberal constituency, I might add. But where 
they lose their liberal foundation in my town meetings is that 
they are convinced that we are going to go bankrupt because of 
undocumented residents in our community. And I get yelled at 
every month at my town meetings and, I think, due to inaccurate 
data, if there is any data. But it is a kind of xenophobia that 
I haven't seen in a long time. And rarely can I say that I am 
disappointed in my constituents. But in this one area, I have 
been just terribly--I have been disappointed that they don't 
take a better approach to that problem that we have.
    I wanted to just establish a few things here. I suspect--I 
am talking to the two JDs here, not the MDs, or the MD-JD 
combination. But there is nothing illegal, is there, about 
collecting data of either ethnicity or race when we collect it 
for Medicare or public health records; is that correct?
    Dr. ITON. It is correct, as far as I understand it.
    Ms. JANG. Yes, that is correct. And, in fact, the Title 6 
regulations require recipients of Federal financial assistance 
to provide the Office for Civil Rights with the information 
necessary to determine whether they are in compliance. And so, 
therefore, recipients have an obligation to collect that 
information.
    Chairman STARK. Then I am going to ask Dr. Blanton just to 
summarize as between Medicare, Medicare Advantage plans, 
private fee-for-service plans. What kind of data collection do 
we have? Do we have good data, sparse data? Can you kind of 
summarize? And what should we do?
    Ms. LILLIE-BLANTON. Right. Our data are very sparse, 
especially on Medicare Advantage plans. In fact, we don't even 
require the same collection of information from Medicare 
Advantage plans as routinely are collected in other 
administrative proceedings. And so we at least need to make 
sure that we have comparable reporting for enrollees in fee-
for-service as we have in----
    Chairman STARK. And what about in the Part D pharmaceutical 
stuff?
    Ms. LILLIE-BLANTON. Unfortunately, I am not----
    Chairman STARK. Anybody know? I don't think we have very 
good data on that.
    Ms. LILLIE-BLANTON [continuing]. Requirements by race, 
ethnicity. I know there are reporting requirements, but I am 
not sure if the data required reporting specifically in Part D.
    So I do think we need to improve on our administrative data 
collection, at least for Medicare Advantage.
    Chairman STARK. Okay. I agree. And, as I say, I hope that 
we can proceed on a nonpartisan or bipartisan basis to begin at 
least to collect more of the data. We should have been doing it 
more thoroughly in Medicare. We don't do it at all in Social 
Security. We do it pretty sparsely, I think, in Medicare. And I 
don't know that we can do away with a lot of the arguments and 
discussions if we can turn--if we can sort out the empirical 
issues before us. And I think that that would be extremely 
important for us.
    Can you comment, Dr. Blanton, on how well the Medicare 
Advantage plans, insofar as we know, have done in terms of 
disparities versus fee-for-service, standard Medicare?
    Ms. LILLIE-BLANTON. Well, only to the extent that there are 
two studies that are cited that, you know, I think give us some 
information. And from both of those studies--one that was by 
Trivedi, who is now at Brown University but I think then was at 
Harvard, and the other by Schneider. And both basically found 
that disparities still exist even in the Medicare Advantage 
program.
    The study by Trivedi is fairly recent, in the sense that 
they tracked over time. And that is the one that actually 
looked at HEDIS measures and found that seven of the nine HEDIS 
measures, there was a narrowing, but still the disparities 
existed. And on two you actually had a widening. And the two 
were very important, because one was glucose monitoring for 
diabetics and the other was cholesterol monitoring for patients 
with heart disease.
    So there is some fairly recent evidence that performance in 
Medicare Advantage plans has not resulted in eliminating 
disparities.
    The work by Schneider is probably cited even more, but it 
is a little older data, but the findings are very similar. I 
mean, they looked at breast cancer, they looked at diabetic, 
eye exams, also looked at follow-up care after hospitalization.
    And, you know, I think the potential exists for better 
coordination, for better care. But I think what Dr. Akhter is 
saying, you have to monitor it. It is not just a matter of 
because the organizational structure there allows for better 
coordination. There still has to be the monitoring to assure 
that the kind of coordination and followthrough occurs, that 
the organizational structure allows or would encourage to have.
    Chairman STARK. Yeah, I have often felt that just to assign 
people, say, as we have, to a managed care plan, we start 
paying them, but we don't know if they ever show up. And 
somehow I have always felt that I am happy to pay them, but I 
think that they ought to somehow interact with the patient.
    I am sorry, Dr. Satel, that you get this, but I can't help 
but ask a couple of things. I was disturbed, to say the least.
    And did any of you go to Harvard Medical School? No.
    Dr. SATEL. Brown.
    Chairman STARK. These guys at Harvard doing research who 
were getting hundreds of thousands of dollars from the various 
parts of PhRMA, which I thought was not very ethical.
    Dr. SATEL. You can't leave psychiatry out of this.
    Chairman STARK. Well, but then--no, no, but the other thing 
then that troubled me--and that is what we are getting to--and 
this comes closer to my home than I like, but the fact that we 
are overmedicating and overdiagnosing children in the psych--
and, I mean, what I am seeing where my 6-year-old twins are 
going to school, you know, half the class on meds? And I think, 
``Holy smokes, Doc. They can't all be''--do you share my 
concern that----
    Dr. SATEL. Yes.
    Chairman STARK [continuing]--that may have been created by 
the makers of these drugs, who have been instructing your 
colleagues at golfing outings and other--help me with that.
    Dr. SATEL. That is a hard question about the interaction. 
But it is--most psychiatrists, apparently except for the 
physician at Harvard who was a large proponent of diagnosing 
childhood bipolar and appeared by most accounts to have a 
fairly low threshold for doing that and also a low threshold 
for urging medication treatment, he----
    Chairman STARK. But also for attention deficit, which is 
one of the more common ones.
    Dr. SATEL. Well, that can often overlap with bipolar or 
appear to look like it. Yeah, these are difficult diagnostic 
issues. And there has been a lot of concern among psychiatrists 
that it is way overdiagnosed and way overprescribed.
    An interesting subset of that concern, however--and this 
has been well-documented--is that within this perhaps exuberant 
tendency to prescribe and to diagnose is subsets of minority 
children who may be underdiagnosed and undertreated. So it is a 
paradox within that larger phenomenon.
    Chairman STARK. Well, you have all been patient and kind. 
And what you have really done is open yourself up for an awful 
lot of extra work after this, when we and our staff ask you if 
you will help us as we try to wind through. We are going to be 
dealing with this issue next year, I am sure. And it is 
important that we understand that just having an insurance plan 
may not guarantee to every resident of this country the right 
medical care or sufficient medical care.
    But I think the witnesses have suggested to us that, as a 
first step, we ought to make sure that at least they have 
access and the money to pay for it, without which they are not 
going to have access. And then we have a whole lot of subtle 
differences that we have to deal with.
    We really do appreciate your taking the effort to be heard 
here. Are there any of you who have a last comment that you 
would like to make to my colleagues?
    Ms. Jones, would you like----
    Mrs. JONES. For the record, there was some research done by 
a researcher at Cleveland State University and Case Western 
Reserve University and university hospitals around low-income 
recipients of healthcare and the cultural impediments to the 
receipt of that care. Unfortunately, as I sit here, I can't 
think of the name of the researcher or the name of the report. 
But if anybody is interested, please feel free to contact me. I 
will get that information for you. It was very interesting 
outcomes with regard to that whole issue of cultural 
sensitivity and a lot of other issues that were barriers to 
access to healthcare.
    Chairman STARK. And the other suggestion that my friend, 
Mr. Becerra, mentioned earlier, but for those of you who have 
some relationship to advocacy groups or our colleagues on the 
other side of the Capitol who need some encouragement, we 
think, to do the right thing, and if you have a lot of extra 
time and we don't have thunderstorms this afternoon, maybe you 
can get over there and push them along a little bit toward what 
we think has been a good job on a bipartisan basis that my 
colleagues did here in the House over a year ago, or just a 
year ago, when we did the CHAMP Act. And we would like to see 
more of that survive.
    And for those of you who are physicians, it isn't just the 
fact that you might get a 10 percent cut, but there is also 
more there that I think will help the entire country in the 
delivery of medical care.
    Thank you all for your patience and your participation.
    The hearing is adjourned.
    [Whereupon, at 12:43 p.m., the Subcommittee was adjourned.]
    [Submissions for the Record follow:]

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             Statement of America's Health Insurance Plans
I. INTRODUCTION
    America's Health Insurance Plans (AHIP) is the national association 
representing approximately 1,300 health insurance plans that provide 
coverage to more than 200 million Americans. Our members offer a broad 
range of health insurance products in the commercial marketplace and 
also have demonstrated a strong commitment to participation in public 
programs.
    We thank the Subcommittee for holding this hearing on healthcare 
disparities and we commend Congresswoman Hilda Solis and Delegate Donna 
Christensen for introducing H.R. 3014, the ``Health Equity and 
Accountability Act,'' as well as Congressman Jesse Jackson, Jr. for the 
introduction of H.R. 3333, the ``Minority Health Improvement and Health 
Disparity Elimination Act.'' We also applaud the Congressional 
TriCaucus for its leadership in promoting a national dialogue on the 
need for solutions to eliminate disparities in healthcare.
    Our industry looks to the Agency for Healthcare Research and 
Quality's (AHRQ) annual National Healthcare Disparities Report as an 
important contributor to understanding continued gaps in care and our 
nation's progress toward reducing racial and ethnic disparities. Health 
insurance plans recognize that we serve an increasingly diverse 
population and that this trend will continue over the next several 
decades. In fact, by 2050, half of all Americans will be minorities. 
This shift in the racial demographics of America poses significant 
challenges to government, business, healthcare providers, and health 
plans to ensure that we are reaching diverse communities and serving 
them at their point of need. The health plan community is uniquely 
situated to address this challenge with meaningful solutions.
    Our statement focuses on two broad topics:

      The importance of collecting data on race and 
ethnicities, based on uniform standards and categories, to identify 
disparities and develop programs that close the gaps in care; and
      Initiatives our industry is pursuing to improve data 
collection and eliminate disparities in healthcare.

II. DATA COLLECTION BASED ON UNIFORM STANDARDS
    Health insurance plans are making significant contributions to this 
debate in the area of data collection. Data are the fundamental 
building blocks for: (1) identifying the differences in care 
experienced by specific populations; (2) developing programs to address 
these differences and ensure a higher standard of care; and (3) 
increasing access to culturally and linguistically appropriate health 
and wellness information, such as addressing language and 
interpretation needs. Recognizing this opportunity, health insurance 
plans are using the data that they are voluntarily collecting on race 
and ethnicity to support culturally and linguistically appropriate 
communications to members, to build wellness, prevention, and chronic 
care programs that are relevant for specific race and ethnic groups, 
and to implement or strengthen quality improvement efforts.
    In 2003, we partnered with the Robert Wood Johnson Foundation 
(RWJF) and commissioned a broad survey to evaluate the extent to which 
health plans voluntarily collect or obtain data on their enrollees' 
race, ethnicity, and primary language using both direct or indirect 
methods. This allowed us to probe barriers to getting data, develop a 
strategy, and implement programs. This original survey found that just 
over half of enrollees were covered by organizations that collect or 
obtain data on the race and ethnicity of their members.
    Despite this early sign of progress, the survey findings also 
identified major concerns as to why health plans choose not to collect 
data on the race and ethnicity of members. Primarily, the answer is 
that health insurance plans are concerned with how enrollees and 
communities will react to this activity. These concerns have been 
validated through AHIP focus groups with African Americans and 
Hispanics/Latinos in 2005, and a consumer survey funded by the RWJF. 
Focus group participants exhibited some willingness to answer questions 
about race, ethnicity, and primary language if they were asked on a 
voluntary basis, collected at the same time as other demographic 
questions, and if the reasons for data collection were fully explained, 
such as for quality improvement efforts.
    In 2006, we partnered with RWJF to conduct a follow-up survey on 
data collection and found that two-thirds of consumers receive their 
health insurance coverage from an organization that collects data on 
the race and ethnicity of members. This is a significant improvement 
over the original 2003 study and an important step in eliminating 
healthcare disparities. We are continuing our collaboration with RWJF 
to conduct two additional surveys in 2008 and 2010 that move from 
assessing the collection of data by health plans to identifying 
strategies our member companies are utilizing to develop tailored 
interventions that meet the needs of diverse populations. AHIP also 
will be conducting health plan interviews to further explore challenges 
and opportunities with data collection and successful strategies to 
improve care through the use of these data.
    Another significant concern is that there is no uniform method or 
standardization in the categories used to collect data by race and 
ethnicity. Instead, conflicting categories are used by various 
government agencies, such as the Centers for Medicaid & Medicare 
Services (CMS) and the Centers for Disease Control & Prevention (CDC), 
even though it is widely recognized that the usefulness of data 
collection efforts in identifying and reducing health disparities is 
largely dependent on the accuracy and sharing of information. To 
address this shortcoming, it is essential for public and private 
stakeholders to work together to develop comprehensive standards that 
will ensure uniformity of data categories for measuring progress in 
reducing disparities across the entire healthcare sector.
    AHIP, the National Health Plan Collaborative (NHPC), the Health 
Research and Educational Trust (HRET), the RAND Corporation, and 
several other public and private entities have stressed the need for 
standardization of race and ethnicity data categories. Currently, the 
NHPC is working with AHRQ and the HHS Office of Minority Health to 
encourage a study committee convened by the IOM to identify best 
practices for data collection and recommend the use of uniform data 
categories for measuring and reporting quality of care across diverse 
populations.
III. INITIATIVES BY HEALTH INSURANCE PLANS
    AHIP's members have been working pro-actively through a number of 
initiatives and partnerships to improve data collection and take steps 
toward eliminating healthcare disparities.
    Eleven major health insurers have formed a public-private 
partnership--the National Health Plan Collaborative--that is working to 
reduce racial and ethnic disparities and improve the overall quality of 
care. This initiative, established in December 2004, is the first 
national effort of its kind to move beyond research and actively test 
possible solutions to inequalities in the delivery of healthcare 
services.
    From 2004 through 2006, a central goal of the Collaborative was to 
test ways to improve the ability of health insurance plans to collect 
and analyze data on race and ethnicity. Other top priorities included 
developing methods of measuring improvement in the care of diabetes for 
specific populations and testing interventions that have the potential 
to improve healthcare quality for racially and ethnically diverse 
populations.
    During the current phase of this initiative, health plans are 
looking at ways to standardize primary data collection, address 
language access services, and create innovative programs that address 
gaps in care. Looking forward, the Collaborative is focused on sharing 
strategies and tools that prove successful in improving healthcare 
quality with healthcare decision-makers and leaders, including other 
health insurance plans serving commercial, Medicare, and Medicaid 
populations. Ultimately, this needs to be an effort involving all 
payors including public programs.
    AHIP's Addressing Disparities in Health program was forged in 2003 
through the leadership of our member organizations to highlight the 
importance of designing quality improvement programs for populations of 
different racial and ethnic needs. This program consists of:

      Four regional workshops conducted across the country to 
educate health plans and key stakeholders about the importance of data 
collection, how to get leadership and community buy-in, and to provide 
recommendations for collecting and analyzing data on race, ethnicity, 
and primary language of their enrollees. Feedback from these trainings 
resulted in the development of a data collection toolkit, Data as 
Building Blocks for Change, for health plans interested in initiating 
racial and ethnic data collection efforts and developing targeted 
interventions.
      Educational sessions with health plan communications 
staff and other health plan professionals on cross-cultural 
communication messaging that reinforces the need for cultural 
sensitivity information for all populations.
      Programs emphasizing an understanding of information 
relevant to race, ethnicity, and culture and its significance to the 
effective communication and delivery of health services. One key 
strategy is to help healthcare professionals break down cultural 
communication barriers through continuing medical education. AHIP, in 
collaboration with the Manhattan Cross Cultural Group, has commissioned 
a continuing medical education course that provides physicians with the 
tools and skills to communicate more effectively with patients from 
diverse backgrounds. To date, over 500 physicians have participated in 
AHIP's cultural competency module that features a case study geared for 
improving asthma care among African Americans. We will be expanding the 
existing cultural competency training modules to new audiences such as 
nurses, case managers, and non-clinical health professionals (e.g., 
health plan customer representatives). The clinical and non-clinical 
modules will include a variety of case studies addressing chronic 
conditions, such as hypertension and asthma, as well as how to better 
serve diverse populations, such as individuals with limited English 
proficiency.
      Health plan ``Models that Work'' to facilitate the 
sharing of information on proven strategies for reducing disparities. 
This clearinghouse will highlight a wide range of health plan 
strategies for reaching out to culturally and ethnically diverse 
populations that are at risk for certain medical conditions. This 
initiative continues our industry's long tradition of sharing 
information on effective models so these programs, or elements of them, 
can be adapted for more widespread use and to benefit more people.

    The industry's efforts are beginning to have an impact. In addition 
to an increase in data collection, plans are analyzing these data to 
determine where health disparities exist and implementing programs to 
address gaps in the treatment of chronic conditions, adherence to 
medications, and the use of preventive services and medical procedures. 
To build upon this progress, we will be reaching out and working with 
key stakeholders to increase patients' awareness about the utility of 
data in improving health and healthcare.
IV. CONCLUSION
    Looking forward, leadership from all stakeholders is the key to 
eliminating disparities in healthcare. We all must come together in 
recognizing that action on this priority is essential to improving 
quality of care for all Americans.
    While data collection and analysis are building blocks to 
eliminating disparities, another very crucial component of our 
challenge is to put the data to use in developing and implementing 
programs to reduce disparities that are relevant to the specific 
communities we serve. To meet this challenge, we need to break out of 
silos and use our collective expertise to work collaboratively on 
initiatives that will have a demonstrable impact in eliminating 
disparities in healthcare and improving overall quality. We stand ready 
to work with the Subcommittee and others to advance these important 
priorities.

                                 
              Statement of American College of Physicians
    As the largest medical specialty society and the second largest 
medical organization in the United States, the American College of 
Physicians (ACP) is committed to eliminating disparities in healthcare 
access and quality. ACP represents 125,000 doctors of internal 
medicine, residents and medical students. The College is addressing 
healthcare disparities in its public policy research, educational 
initiatives and foundation activities. ACP applauds Chairman Pete Stark 
for holding this hearing to improve understanding of the many factors 
that contribute to health disparities, including access to care. The 
College recognizes that addressing this issue is vital to improving the 
health status of Americans and achieving a highly performing healthcare 
system that is accessible to all.
    Racial and ethnic disparities in healthcare are well-documented. 
Addressing these inequities became a national movement with the 
development of the Healthy People 2010 goals and objectives. In 2002 a 
landmark report was released by the Institute of Medicine, Unequal 
Treatment: Confronting Racial and Ethnic Disparities in Healthcare. 
Since then, a significant amount of research has increased our 
understanding of the scope and causes of disparities. Despite these 
efforts, large gaps in access, quality of care and health outcomes 
still persist. Earlier this year, the Agency for Healthcare Research 
and Quality (AHRQ) released its annual National Healthcare Disparities 
Report, which found that disparities in healthcare quality and access 
have not decreased, and for many indicators, the gaps are expanding. 
Specifically, the 2007 report notes that:

    1.  Blacks had a rate of new AIDS cases 10 times higher than 
Whites.
    2.  Asian adults age 65 and older were 50% more likely than Whites 
to lack immunization against pneumonia.
    3.  American Indians and Alaska Natives were twice as likely to 
lack prenatal care in the first trimester, compared with 
Whites.i

    Timely access to appropriate healthcare is critical to improving 
health outcomes. It is undeniable that uninsurance is a major barrier 
to eliminating healthcare disparities. According to the AHRQ report, 
individuals without health insurance fared worse than individuals with 
private insurance on all access measures and almost 90% of quality 
measures. Compared with the insured, the uninsured are about six times 
as likely to lack a usual source of care and nearly three times as 
likely not to get care as soon as wanted for illness or injury. 
Unfortunately, the uninsured rates are high among many racial and 
ethnic minorities. In 2006, 49% of Hispanics and 28% of African 
Americans adults (ages 18 to 64) were uninsured, compared with 21% of 
whites and 18% percent of Asian Americans.i The College 
advocates that all Americans should have affordable health insurance 
coverage to eliminate the financial barriers to accessing care.
---------------------------------------------------------------------------
    \i\ Agency for Healthcare Research and Quality. 2007 National 
Healthcare Disparities Report. Rockville, MD: U.S. Department of Health 
and Human Services, Agency for Healthcare Research and Quality; 
February 2008. AHRQ Pub. No. 08-0041.
---------------------------------------------------------------------------
    The College also recognizes that disparities exist even among the 
insured. It is for this reason that ACP is deeply committed to 
improving access to care through a delivery model called the patient-
centered medical home. This team-based model of care, led by a personal 
physician, provides continuous and coordinated care to maximize health 
outcomes. Recent research has shown that many racial and ethnic 
disparities related to access and quality are reduced or eliminated 
when patients have a medical home. Among adults with a medical home, 
Blacks and Hispanics were just as likely as Whites to receive 
preventive care reminders, which have been proven to increase the rates 
of routine preventive screenings.ii Ensuring all individuals 
have a medical home will require restructuring of healthcare deliver 
systems, including payment structures to support patient-centered care.
---------------------------------------------------------------------------
    \ii\ Beal AC, Doty MM, Hernandez SE, Shea KK, and Davis K. Closing 
the Divide: How Medical Homes Promote Equity in Healthcare: Results 
From The Commonwealth Fund 2006 Healthcare Quality Survey, The 
Commonwealth Fund, June 2007.
---------------------------------------------------------------------------
    Effective patient-provider communication increases patient 
understanding and is a critical component of patient-centered care. 
Unfortunately, racial and ethnic minorities are more likely to report 
poor communication with health providers than their White 
counterparts.i Approximately 52 million Americans speak a 
language other than English at home. Of these individuals, more than 
half speak English less than ``very well'' and are considered limited 
English proficient (LEP) patients.iii Language barriers can 
result in the exchange of inaccurate or incomplete information, which 
can affect access to and delivery of care and healthcare costs. LEP 
patients disproportionately underutilize less costly preventive 
care.iv However, when competent language services are 
available, LEP individuals can communicate effectively with their 
healthcare providers, improving their encounters and health outcomes. A 
number of federal and state policies require healthcare providers who 
receive federal funds to ensure access to services for patients with 
LEP. However, often times these services are not being offered because 
of time, costs, and availability of qualified interpreters.v
---------------------------------------------------------------------------
    \iii\ U.S. Census Bureau. Language Spoken at Home for the 
Population 5 Years and Over, Tbl B16004, data from 2005 American 
Community Survey.
    \iv\ AM. Doty. Hispanic Patients' Double Burden: Lack of Health 
Insurance and Limited English. The Commonwealth Fund; February 2003.
    \v\ American College of Physicians. Language Services for Patients 
with Limited English Proficiency: Results of a National Survey of 
Internal Medicine Physicians. Philadelphia: American College of 
Physicians; 2006: Position Paper. (Available from American College of 
Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.) 
Accessible at http://www.acponline.orgK/advocacy/where_we_stand/policy/
lep_paper.pdf.
---------------------------------------------------------------------------
    An ACP survey found that the majority of practices represented by 
internists that have LEP patients provide language services. However, 
these services are limited and are typically provided by a bilingual 
physician or staff member and hardly any practices rely on external 
sources for language services or provide such services during off 
hours. In addition, few physicians perceived a need for tools or 
training to assist their practices in providing language 
services.v A clearinghouse to provide translated documents 
and patient education materials would be useful, but providing 
reimbursement for the added costs of clinical time and language 
services would be the most effective means of expanding the use of 
language services.v
    Language is just one aspect of an individual's culture that may 
affect patient-provider communication, quality of the encounter and 
patient outcome. Physicians and other healthcare providers must realize 
the impact of culture on health status. There are many negative health 
consequences that could result from ignoring culture, including missed 
opportunities for screening because of a lack of familiarity with the 
prevalence of conditions among certain minority groups; failure to take 
into account differing cultural responses to prescription medication; 
lack of knowledge about traditional remedies, leading to harmful drug 
interactions; and diagnostic errors resulting from 
miscommunication.vi Research has shown that quality 
healthcare requires attention to differences in culture--the 
``integrated pattern of human behavior that includes thoughts, 
communications, actions, customs, beliefs, values and institutions of a 
racial, ethnic, religious or social group.''vii
---------------------------------------------------------------------------
    \vi\ Brach C, Fraser I. Can cultural competency reduce racial and 
ethnic health disparities? A review and conceptual model. Med Care Res 
Rev. 2000;57 Suppl 1:181-217.
    \vii\ Betancourt JR, Green AR, Carillo JE. The Commonwealth Fund: 
Cultural Competence in Healthcare: Emerging Frameworks and Practical 
Approaches. New York: The Commonwealth Fund; October 2002.
---------------------------------------------------------------------------
    Eliminating health disparities will require an adequate supply of 
culturally-competent healthcare providers. Cultural competence in 
healthcare has been defined as the ability of systems to provide care 
to patients with diverse values, beliefs and behaviors, including 
tailoring delivery to meet patients' social, cultural and linguistic 
needs. Cultural competence techniques have been shown to effectively 
change provider and patient behavior by improving communication, 
increasing trust, improving racially or ethnically specific knowledge 
of epidemiology and treatment efficacy, and expanding understanding of 
patients' cultural behaviors and environment.viii 
Accordingly, the College supports cultural competency training that is 
incorporated in the training and development of all healthcare 
providers, at all levels.ix
---------------------------------------------------------------------------
    \viii\ Brach C, Fraser I. Reducing disparities through culturally 
competent healthcare: an analysis of the business case. Quality 
Management in Healthcare. 2002; 10:15-28.
    \ix\ American College of Physicians. Racial and Ethnic Disparities 
in Healthcare. Philadelphia: American College of Physicians; 2003: 
Position Paper (Available from American College of Physicians, 190 N. 
Independence Mall West, Philadelphia, PA 19106.)
---------------------------------------------------------------------------
    A diverse workforce of health professionals is also an integral 
part of eliminating disparities among racial and ethnic minorities. 
ix-x Currently, many racial and ethnic minority groups are 
poorly represented in the health professions, relative to their 
proportion in the overall U.S. population. Increasing the diversity of 
the healthcare workforce is a key to increasing access to care and 
improving the quality of care for minorities. Minority staff, because 
of shared cultural beliefs and common language, may improve 
communication, create a more welcoming environment, and structure 
health systems to better reflect the needs of minority communities. 
Also, racial and ethnic minorities are more likely to serve in a 
community of underrepresented individuals.xi-xii National 
and local workforce policies are needed to:
---------------------------------------------------------------------------
    \x\ Association of American Medical Colleges. Diversity in the 
Physician Workforce: Facts & Figures 2006. Washington, D.C.: 
Association of American Medical Colleges;
    \xi\ Komaromy M, Grumbach K, Drake M, et al. The role of Black and 
Hispanic physicians in providing healthcare for underserved 
populations. NEJM.1996;334(2):1305-10.
    \xii\ Stinson MH, Thurston NK. Racial matching among African-
American and Hispanic physicians and patients. J Human 
Resources.2002;37(2):410-28.

      Strengthen the education of racial and ethnic minorities 
at all levels in the areas of math and science to create a larger pool 
of qualified minority applicants for medical school.
      Revitalize efforts to improve medical and health 
professional school matriculation and graduation rates of minority 
students. ACP supports the consideration of race and ethnicity in 
determining admissions to institutions of higher education.
      Expand programs that provide outreach to encourage 
minority enrollment in medical and health professional schools.
      Increase efforts to recruit and retain minority medical 
school faculty.
      Enhance funding for programs and initiatives that work to 
increase the number of healthcare providers in minority communities.

    Eliminating health disparities and improving quality of care 
requires evidence-based policies and programs. Research to identify 
sources of disparities, as well as effectiveness of initiatives 
targeted to eliminate disparities, will necessitate the collection of 
better data on race, ethnicity, and primary language using reliable and 
standardized measurement tools. Unfortunately, inadequate data 
continues to limit the analysis of health disparities.xiii 
ACP supports efforts to improve collection of racial and ethnic 
information within the healthcare system. ACP has supported legislative 
efforts to eliminate disparities in healthcare, improve collection of 
racial and ethnic data from Medicare participants and to incorporate 
race, ethnicity, and primary language measures in quality improvement 
projects. The College regards research to be a vital part of 
identifying, monitoring, and addressing disparities in healthcare that 
disadvantage racial/ethnic minorities.
---------------------------------------------------------------------------
    \xiii\ Billheimer LT, Sisk JE. Collecting Adequate Data on Racial 
and Ethnic Disparities in Health: The Challenges Continue. Health 
Affiars. 2008; 27 (2):383-391.
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Conclusion
    The American College of Physicians appreciates the opportunity to 
provide the Health Subcommittee with this summary of our views on 
eliminating healthcare disparities. We recognize that health 
disparities are multi-dimensional and will require comprehensive 
efforts to eradicate the gaps that currently exist. We urge the 
Subcommittee to continue to address this critically important issue.

                                 
         Statement of the American Dental Education Association
    The American Dental Education Association (ADEA) represents all 
accredited dental schools, dental residency training programs and 
allied dental programs in the United States, as well as the faculty, 
dental residents, and dental and allied dental students at these 
institutions.\1\ In these academic dental institutions (ADI) future 
practitioners and re searchers gain their knowledge; the majority of 
dental research is conducted; and significant dental care is provided.
---------------------------------------------------------------------------
    \1\ There are 57 dental schools, 714 dental residency training 
programs, 285 dental hygiene programs, 271 dental assisting programs 
and 21 dental laboratory technology programs in the United States.
---------------------------------------------------------------------------
    U.S. dental schools operate dental clinics and serve as safety net 
providers. As such, they are the dental homes to a broad array of 
vulnerable and underserved low-income patient populations, including 
racially and ethnically diverse patients; elderly and homebound 
individuals; migrants; mentally, medically or physically disabled 
individuals; institutionalized individuals; HIV/AIDS patients; Medicaid 
and State Children's Health Insurance Program (SCHIP) children; and 
uninsured individuals.
    In addition to providing oral health services to vulnerable and 
underserved communities through clinics associated with dental schools, 
ADEA has partnered with the Association of American Medical Colleges 
(AAMC) to recruit and prepare underrepresented minority (URM) students 
for the health professions. Building a diverse healthcare workforce, 
which can better serve the needs of a culturally, ethnically, and 
racially diverse population, is a critical step in addressing the oral 
health disparities that now exist in both rural and urban communities.
Disparities in Oral Health
    The first-ever U.S. Surgeon General's report found that there are 
``profound and consequential oral health disparities within the 
population,'' particularly among ``racial and ethnic minorities, rural 
populations, individuals with disabilities, the homeless, immigrants, 
migrant workers, the very young, and the frail elderly.'' \2\ These 
disparities, the report asserts, have resulted in a ``silent epidemic 
of dental and oral disease affecting the most vulnerable among us.'' 
This disturbing reality, in combination with the current shortage of 
dental school faculty, the scarcity of underrepresented minority (URM) 
dentists, and the need for targeted incentives to draw dentists to 
practice in rural and underserved communities, makes the Subcommittee's 
examination of health disparities timely and necessary.
---------------------------------------------------------------------------
    \2\ U.S. Department of Health and Human Services. Oral health in 
America: a report of the surgeon general. Rockville, MD: U.S. 
Department of Health and Human Services, National Institute of Dental 
and Craniofacial Research, National Institutes of Health, 2000.
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    The challenge facing policymakers and the dental community is not 
only how to address the oral health disparities that exist in our 
nation but also how to improve access to oral healthcare. According to 
Delta Dental Plans Association and the National Association of Dental 
Plans, 134 million American adults and children do not have dental 
insurance. The lack of insurance is a significant barrier to receiving 
needed preventive and restorative care. Having insurance, however, does 
not guarantee quick access to dental care.
    Despite concerted efforts by Congress and the dental community to 
address issues affecting access to dental care, there has been little 
substantive progress made since the untimely death of 12-year old 
Deamonte Driver in February 2007. This Maryland boy died from an 
infection caused by an abscessed tooth that spread to his brain. Timely 
delivery of appropriate dental care at any point along the trajectory 
from cavity to root canal to abscess could have saved Deamonte's life 
and the state of Maryland nearly $250,000. This tragedy could have been 
avoided if his Medicaid coverage had not lapsed and if he had had 
better access to dental care. In this regard ADEA supports Congress' 
continuing bipartisan effort to include a guaranteed dental benefit in 
the bill to reauthorize the State Children's Health Insurance Program 
(SCHIP). ADEA pledges to work for passage of this important legislation 
in the 111th Congress.
U.S. Population and the Dental Workforce
    The U.S. Bureau of Labor Statistics (BLS), which placed the number 
of practicing dentists at 161,000 in 2006,\3\ projects a 9 percent 
growth in the number of dentists through 2016. This rate would bring 
the total number of practicing dentists to 176,000. The vast majority 
of the professionally active dentists in the U.S. are White non-
Hispanic. At the present time the U.S. population is 303,375,763.\4\ At 
the time of the last census, when there were 22 million fewer people, 
the largest segment of the U.S. population was White (75 percent) but 
an increasing percentage was minority with 35.3 million (13 percent) 
Latino, and 34.6 million (12 percent) Black or African Americans.
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    \3\ U.S. Bureau of Labor Statistics, at: http://www.bls.gov/oco/
content/ocos072.stm, February 5, 2008.
    \4\ U.S. Bureau of the Census, at: http://www.census.gov/
population/www/popclockus.html, February 5, 2008.
---------------------------------------------------------------------------
    According to the U.S. Surgeon General, the ratio of dentists to the 
total population has been steadily declining for the past 20 years, and 
at that rate, by 2021, there will not be enough active dentists to care 
for the population. The number of Dental Health Professions Shortage 
Areas (D-HPSAs), designated by the U.S. Health Resources and Services 
Administration (HRSA), has grown from 792 in 1993 to 3,527 in 2006. In 
1993, HRSA estimated 1,400 dentists were needed in these areas; by 
2006, the number grew to 9,164. Nearly 47 million people live in D-
HPSAs across the country. Although it is unknown how many of these 
areas can financially support a dentist or attract a dentist by virtue 
of their infrastructure or location, it is clear that more dentists are 
needed in these areas.
    The disproportionate burden of oral diseases and disorders 
indicates that specific population groups are in greater need of oral 
healthcare. Unfortunately, millions of Americans experience dental pain 
daily and cannot afford to buy dental insurance or pay for dental care 
out of pocket. Since few oral health problems in their early stages are 
life-threatening, people often delay treatment for long periods of 
time. Often, when they do seek care, it is in hospital emergency rooms 
or other venues in the dental safety-net system, that is, academic 
dental institutions clinics, community health centers, school-based 
clinics, municipal clinics, etc. This system of care is inadequate to 
effectively deal with the magnitude of the problem. Most ADI clinics 
are filled to capacity and have long waiting lists.
Diversity in Dental Schools
    The number of African American, Hispanic, and Native American 
students in dental schools remains disproportionate to their numbers in 
the U.S. population. In 2006, underrepresented minority (URM) students 
comprised 12.4 percent of the applicants and 11.6 percent of first-year 
enrollees. Asian/Pacific Islanders and whites comprised 69.7 percent of 
applicants and 71.1 percent of first-year enrollees. The proportion of 
URM students applying and enrolling in U.S. dental schools is far less 
than the proportion of URMs in the communities served by the dental 
school. For example, during the 2003-04 academic year, 7 percent of 
dental students enrolled at the University of California Los Angeles 
(UCLA) and the University of Southern California (USC) were Hispanic, 
while 46.5 percent of the Los Angeles population was Hispanic. Also, in 
2003-04, total African American enrollment at all U.S. dental schools 
was 5.41 percent, while 12.8 percent of the U.S. population were black. 
The proportion of URM dentists also remains significantly lower than 
the proportion of URMs in the U.S. population. Currently, about 6.8 
percent of professionally active dentists are URM, while 27.9 percent 
of the U.S. population are URM. Increasing diversity in the dental 
profession is vital to the future of the profession and it is central 
to achieving optimal oral health for racial and ethnic minority groups, 
which experience a higher level of oral health problems and have 
limited access to dental care.
Response from Academic Dentistry
    Recognizing that enrollment of underrepresented minorities (URM) 
students has remained largely stagnant, the American Dental Education 
Association has become actively engaged in supporting programs that 
bolster underrepresented minority recruitment and retention into 
dentistry and has partnered with foundations and others to make 
progress:

      The ``Pipeline, Profession, and Practice: Community-Based 
Dental Education'' program sponsored by the Robert Wood Johnson 
Foundation (RWJF). This program has also been supported by the 
California Endowment and the W.K. Kellogg Foundation. The five-year 
initiative launched in 2003 to help increase access to oral healthcare. 
This program provided institutions with grants to link their schools to 
communities in need of dental care and to boost their URM and low-
income (LI) student enrollment numbers. Dental Pipeline I successfully 
concluded with 15 dental schools participating. Dental students and 
residents in the program provided care to thousands of low-income 
patients through partnerships with 237 community-based clinics.
      The ``Summer Medical and Dental Education Program 
(SMDEP),'' a collaborative program administered by ADEA and the 
Association of American Medical Colleges (AAMC) and funded by the 
Robert Wood Johnson Foundation-RWJF, offers freshman and sophomore 
college students intensive and personalized medical and dental school 
preparation. The program runs from summer 2006 through summer 2009 and 
offers academic enrichment for disadvantaged undergraduate freshmen/
sophomores. Nearly 1,900 students have participated (333 dental and 
1,564 medical). Seventy-one percent of the participants have been 
women, 48 percent have been Black or African American, 21 percent have 
been Hispanic or Latino, and 2 percent have been American Indian.
      ADEA has received a grant from the Josiah Macy, Jr. 
Foundation to increase the diversity of the dental workforce in the 
United States. The grant funds the planning process to implement a 
flexible seven-year dental curriculum, modeled after one currently used 
in medicine, to prepare a new cadre of underrepresented minority and 
low-income (URM/LI) students for the practice of dentistry. The program 
aims to move toward the implementation of a seven-year curriculum that 
will significantly increase the number of URM students that receive a 
dental education and then enter the workforce as dental school 
graduates.
Recommendations to Congress
    There are several straightforward steps that Congress can take to 
immediately address the oral health challenges we face. The American 
Dental Education Association stands ready to work with Congress to 
address oral health disparities and ameliorate access to dental care 
problems. Specifically, ADEA recommends:
1. Strengthen and Improve Medicaid
    Early intervention is the key to assuring that children have good 
oral health. While children enrolled in Medicaid have a Federal 
guarantee for access to dental services through the Early Periodic 
Screening Diagnosis and Treatment program (EPSDT) \5\, accessing 
services is often difficult due to low reimbursement rates and the 
number of participating dentists. Unfortunately, millions of children 
covered by Medicaid are not getting regular dental care. We urge 
Congress to work with states to increase reimbursement rates and to 
simplify and streamline the application, enrollment and recertification 
process for Medicaid, and lessen the administrative burden associated 
with this program.
---------------------------------------------------------------------------
    \5\ Medicaid statutes, PL 101-239, Section 6403, require that 
dental services for children shall at a minimum, include relief of pain 
and infection, restoration of teeth, and maintenance of dental health. 
Medicaid guarantees medically necessary services, including preventive 
dental care, under its EPSDT provision.
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2. Include Dental Guarantee in SCHIP
    Congress can address oral health disparities and increase access to 
dental care for vulnerable children covered by the State Children's 
Health Insurance Program (SCHIP) by: 1) Establishing a federal 
guarantee for dental coverage in SCHIP; 2) Developing a dental wrap-
around benefit in SCHIP; 3) Facilitating ongoing outreach efforts to 
enroll all eligible children in SCHIP and Medicaid; and 4) Ensuring 
reliable data reporting on dental care in SCHIP and Medicaid.
3. Restore Funding for Title VII Diversity Programs
    The only federal programs whose goal it is to strengthen and 
diversify the health professions are the Title VII Centers of 
Excellence (COE) and Healthcareers Opportunity Program (HCOP). These 
programs work in diverse communities to achieve this national goal. The 
programs remain woefully under-funded after several years of 
significant cuts. Congress should restore their funding at least to FY 
2005 levels.


------------------------------------------------------------------------
                   Table 4: COE and HCOP Funding by FY
-------------------------------------------------------------------------
                          FY05         FY06         FY07         FY08
------------------------------------------------------------------------
COE                   $35 million  $12 million  $11.88       $12.77
                                                 million      million
------------------------------------------------------------------------
HCOP                  $33 million  $4 million   $3.9         $9.8
                                                 million      million
------------------------------------------------------------------------

    The COE and HCOP programs assist institutions in developing a more 
diverse applicant pool; establishing and strengthening the academic 
performance of under-represented minority students enrolled in health 
professions schools; improving institutional academic, research and 
library capacity; and enhancing pipeline efforts to undergraduate and 
pre-college students. Also, HCOP makes grants to community-based health 
and educational entities to support student pipeline and other academic 
activities.
4. Prioritize Dental Access in Rural Health Clinics
    Rural communities across America rely on rural health clinics to 
provide care to everyone, including those who are uninsured or 
underinsured. Full-service community hospitals in rural areas are 
safety net providers, offering basic health services but often oral 
healthcare is unavailable. To improve the oral health status of rural 
America, Congress should incentive rural health clinics to add 
preventive and restorative dental services to the list of core services 
they provide on-site or under arrangement.
Oral Healthcare and Reform
    A sustained federal commitment is needed to meet the challenges 
that oral health disparities and oral disease pose to our nation's 
citizens, including children, the vulnerable and underrepresented 
minorities. It is imperative that Congress address the growing needs in 
educating and training health professionals, including dentists, to 
meet the growing and diverse needs of the future. The American Dental 
Education Association is eager to partner with Congress to develop and 
implement a national oral health plan that eliminates oral health 
disparities; guarantees access to dental care for everyone; bolsters 
the nation's oral health infrastructure; and successfully addresses 
academic and dental workforce shortages.
Consequently, oral healthcare coverage and access to affordable oral 
        health services must be included as integral components in any 
        proposal to reform the U.S. healthcare system.
Contacts:  Myla Moss ([email protected]) at 289-7201 ext. 170 Deborah 
Darcy ([email protected]) at 289-7201 ext. 163

                                 
          Statement of American Dental Hygienists' Association
    On behalf of the American Dental Hygienists' Association (ADHA), 
thank you for the opportunity to submit testimony on ``Addressing 
Disparities in Health and Healthcare: Issues for Reform.'' ADHA 
applauds Subcommittee Chairman Stark for holding a hearing to examine 
disparities in health and issues that will impact discussion on policy 
efforts that seek to reform our healthcare system. This is a timely and 
important issue and ADHA is pleased to participate in the dialogue 
about disparities that impact the delivery of oral healthcare and ways 
in which those disparities can be lessened or eliminated. Oral health 
is a part of total health and the oral healthcare delivery system 
requires reform along with the medical care delivery system.
    ADHA is the largest national organization representing the 
professional interests of more than 150,000 licensed dental hygienists 
across the country. Dental hygienists are oral health professionals 
licensed in each of the fifty states who are committed to improving the 
nation's oral health, a fundamental part of overall health and general 
well-being. In order to become licensed as a dental hygienist, an 
individual must graduate from an accredited dental hygiene education 
program and successfully complete a national written and a state or 
regional clinical examination.
    As an organization, ADHA has a fundamental commitment to better 
oral healthcare for all people and advocates in support of oral health 
programs for underserved populations. ADHA and its state associations 
actively pursue efforts to increase the public's ability to access 
preventive oral healthcare services.
    Unfortunately, disparities in the delivery of healthcare services 
tend to be even more pronounced within oral health. According to the 
U.S. Surgeon General, over 108 million Americans lack dental 
insurance--more than 2.5 times the number of Americans who lack medical 
insurance. The May 2000 report, Oral Health in America: A Report of the 
Surgeon General, brought to light the socioeconomic, regional, and 
educational barriers that contribute to oral healthcare disparities. 
The report also specifically noted that disparities are exacerbated by 
the lack of community programs that provide needed oral healthcare 
services.
    The death of twelve-year old Deamonte Driver in 2007 from 
complications of an abscessed tooth provided all of us with a tragic 
reminder that lack of access to oral health services can have serious--
even fatal--consequences. Deamonte's death from a dental infection is 
particularly heartbreaking because virtually all dental disease is 
fully preventable. But, despite this proven prevention capacity, dental 
caries (tooth decay) remains the single most common chronic disease of 
childhood, five times more common than asthma. Dental caries--which is 
an infectious transmissible disease--still affects more than half of 
all children by second grade. Until the oral healthcare delivery system 
is restructured to improve access to care, children will continue to 
suffer needlessly from preventable dental disease.
    Preventable dental disease disproportionately affects our Nation's 
most vulnerable populations, including many children eligible for 
Medicaid and the State Children's Health Insurance Program (SCHIP). The 
current oral healthcare delivery system is simply not meeting America's 
oral health needs, particularly the needs of Medicaid and SCHIP 
children such as Deamonte Driver. As prevention specialists, dental 
hygienists understand that recognizing the connection between oral 
health and total health can prevent disease, treat problems while they 
are still manageable, conserve critical healthcare dollars, and save 
lives. While the practice of dental hygiene varies from state to state, 
in the 26 states that allow patients to directly access dental hygiene 
services, dental hygienists are able to work more readily in public 
health settings--bringing patients otherwise disenfranchised from the 
oral healthcare system into the pipeline for care.
    As one of the fastest growing healthcare occupations in the 
country, as identified by the Bureau of Labor Statistics (BLS), the 
dental hygiene profession is well placed to significantly impact the 
delivery of care in the U.S. BLS data indicates the number of dental 
hygienists is expected to grow by more than 30 percent from 2006--2016. 
The population of dentists is growing at a much slower rate and 
according to the BLS; the growth of the profession is not anticipated 
to keep pace with the need for dental care in coming years. Dental 
hygienists are committed to working as part of a comprehensive 
healthcare team in order to improve access to oral health services. 
Indeed, one of ADHA's enunciated priorities is to ``work in partnership 
with dentists to advance the oral health of patients.''
    ADHA welcomes the opportunity to work with the Subcommittee and all 
Members of Congress as well as the entire dental community and all 
those who care about the nation's oral health to work towards solutions 
to improve access to oral healthcare and ensure that all Americans have 
access to oral healthcare providers in the future. Indeed, healthcare 
reform efforts present an opportunity for ADHA to demonstrate its 
commitment to partnership with organized dentistry as well as other 
stakeholders in healthcare. Certainly, the elimination of healthcare 
disparities will require a collective effort and will involve efforts 
to reform and improve the current system.
U.S. Surgeon General Report on Oral Health in America Confirms that 
        Oral Health is a Fundamental Part of Overall Health
    In May 2000, the U.S. Surgeon General issued Oral Health in 
America: A Report of the Surgeon General. This landmark report confirms 
that oral health is an integral part of total health and that good oral 
health can be achieved. The Surgeon General's Report on Oral Health 
challenges all of us--in both the public and private sectors--to 
address the compelling evidence that not all Americans have achieved 
the same level of oral health and well-being. The Report describes a 
``silent epidemic'' of oral diseases, which affect our most vulnerable 
citizens--poor children, the elderly and many members of racial and 
ethnic minority groups.
    Key findings enumerated in the Report include:
    1. Oral diseases and disorders in and of themselves affect health 
and well-being throughout life.
    2. Safe and effective measures exist to prevent the most common 
dental diseases: dental caries (tooth decay) and periodontal (gum) 
diseases.
    3. Lifestyle behaviors that affect general health such as tobacco 
use, excessive alcohol use, and poor dietary choices affect oral and 
craniofacial health.
    4. There are profound and consequential oral health disparities 
within the U.S. population.
    5. More information is needed to improve America's oral health and 
eliminate health disparities.
    6. The mouth reflects general health and well-being.
    7. Oral diseases and conditions are associated with other health 
problems.
    8. Scientific research is key to further reduction in the burden of 
diseases and disorders that affect the face, mouth and teeth.
U.S. Surgeon General Notes Significant Disparities in Oral Health
    The Surgeon General's Report on Oral Health highlights numerous 
disparities in oral health relative to age, race, gender, insurance 
status, and income level. Some of the significant disparities noted 
include:

      Children from families without dental insurance are three 
times more likely to have dental needs than children with either public 
or private insurance.
      Poor children suffer twice as much dental caries as their 
more affluent peers.
      34% of black older Americans have lost all of their teeth 
compared to 23% of whites.
      A national survey found that employed Hispanic adults 
were twice as likely to have untreated dental caries as non-Hispanic 
whites
      In general, the American Indian and Alaska Native 
populations have much greater rates of dental caries and periodontal 
disease in all age groups than the general U.S. population.
      Adult females are less likely than males at each age 
group to have severe periodontal disease as measured by periodontal 
loss of attachment of 6 mm or more for any tooth.

    As follow-up to Oral Health in America, the Surgeon General issued 
A Nation Call to Action to Promote Oral Health in 2003 which called on 
stakeholders in oral health to change perceptions of oral health, 
overcome barriers to care, and increase collaborations. The report also 
called on stakeholders to make strides to ``increase oral health 
workforce diversity, capacity, and flexibility''--moving towards 
optimal use of healthcare professionals.
The Oral Healthcare Delivery System Must be Reformed Along with the 
        Medical Care Delivery System
    As prevention specialists in one of the fastest growing 
professions, dental hygienists are well positioned to work as part of 
the overarching effort to increase access to oral healthcare, 
particularly for those in underserved populations. Workforce experts 
have recognized that dental hygienists can and must play an increasing 
role if the nation's oral health needs are to be met. An article in 
Health Affairs explored the oral health workforce and found:

        ``abundant evidence that a sizable segment of the population 
        does not have access to private [dental] care, while the dental 
        safety net is ``poorly defined and underdeveloped.'' Dentists' 
        participation in Medicaid is not robust; community health 
        centers and public health facilities have scant dental 
        capabilities; and Medicare offers no dental coverage. ``Radical 
        steps'' will be needed to correct ``a growing disconnect 
        between the dominant pattern of practice . . . and the oral 
        health needs of the nation,'' . . . including new practice 
        settings for dental care, integration of oral and primary 
        healthcare, and expanded scope of practice for hygienists and 
        other allied professions.''

    Increasingly, states are recognizing the benefits associated with 
policy changes that make it easier for dental hygienists to work with 
less supervision in settings outside of the private dental office. 
Currently, 26 states have policies in place that enable patients to 
access preventive services offered by dental hygienists via direct 
access, meaning a patient can be treated without the presence or prior 
authorization of a dentist. In the past ten years, 23 states have 
enacted policies that facilitate care via direct access, making it 
easier for dental hygienists to treat patients in schools, community 
clinics, long term care facilities, mobile health units, and other 
public health settings.
    Similarly, the last decade has brought about an insurgence of 
policies at the state level to allow dental hygienists to be directly 
reimbursed by Medicaid for dental services included in their scope of 
practice. Currently, 12 states allow for direct Medicaid reimbursement, 
making it easier for dental hygienists to work within the Medicaid 
system to provide care.
    These types of policy changes better leverage the existing dental 
hygiene workforce and make care more accessible for those who currently 
have difficulty securing services in the private dental office. 
Bringing patients into the oral healthcare system for preventive and 
other oral healthcare services through additional access points such as 
schools, community health centers, and nursing homes can avert more 
costly restorative care, allow appropriate referral to dentists, and 
help save valuable healthcare dollars in the long-run.
A New Oral Healthcare Provider to Improve Access to Care: The Advanced 
        Dental Hygiene Practitioner
    In response to the Surgeon General's identified need to enhance the 
oral health workforce capacity, ADHA has supported efforts to improve 
the delivery of care by dental hygienists, but has also striven to come 
up with new ideas to improve the system. ADHA has defined a new oral 
healthcare provider, the Advanced Dental Hygiene Practitioner (ADHP). 
This new provider would provide preventive, therapeutic, diagnostic, 
prescriptive, and minimally invasive restorative services directly to 
underserved Americans. The ADHP would be a member of a comprehensive 
healthcare team, and would refer patients in need of more advanced oral 
healthcare services to dentists. This new provider would be state-
licensed and be a graduate of a Master's degree ADHP program.
    ADHA has been working in a transparent and inclusive fashion to 
shape this advanced practitioner concept. An ADHP Advisory Committee 
that included representatives of major oral healthcare organizations, 
the Federal Government, health advocacy groups and others interested in 
oral health access issues was convened by ADHA in 2005 to solicit 
feedback on the new provider. ADHP competencies have been developed by 
the ADHP Task Force which worked for two years to systematically define 
the educational domains and competencies that will serve as the 
framework for ADHP educational programs. ADHP competencies were 
finalized by ADHA's Board of Trustees in 2008 and are available at 
www.adha.org.
    The ADHP will function as a mid-level oral healthcare provider akin 
to the nurse practitioner in medicine. The medical fields have long 
accepted mid-level providers as integral components of the healthcare 
team able to reach out to patients currently unable to access care. 
Similarly, the ADHP is being developed to provide a new point of entry 
into the oral healthcare system for those currently disenfranchised, 
offering a wider range of services in public health settings. A key 
component to making care accessible is offering the services patients 
need most in settings they are able to reach, such as schools, public 
health clinics, and nursing homes.
    In the National Governors Association Center for Best Practices 
issue brief entitled, ``State Efforts to Improve Children's Oral 
Health,'' the authors noted that ``Maximizing auxiliary personnel can 
increase access to preventive services. . . . In most states, the scope 
of practice for auxiliary personnel is quite restricted, even when the 
services necessary don't require a dentist. Some states are 
restructuring their Dental Practice Acts to maximize the use of dental 
hygienists.'' Two illustrative examples highlighted by the NGA are set 
forth below.

      Maine changed the rules governing the practice of 
hygienists to allow them to practice in public health settings such as 
school health centers, hospitals, and public clinics without a dentist 
on site--provided that the hygienists have an established relationship 
with a dentist. The state believes this strategy offers great promise 
for addressing dentist shortages. In 2008, the state passed legislation 
to allow dental hygienists to own and operate dental hygiene practices.
      Minnesota passed legislation in 2001 to allow dental 
hygienists to perform certain primary care functions without dentist 
supervision, provided they are employed by one of the following 
entities: hospitals, nursing homes, group homes, home health agencies, 
state-operated facilities, federal, state or local public health 
facilities, or community or tribal clinics. In order to qualify, the 
hygienist must meet prescribed practice experience requirements and 
must engage in a collaborative agreement with a dentist who authorizes 
and accepts responsibility for these hygienist services.

    Minnesota is slated to become the first state to house an ADHP 
education program. In late 2007, Metropolitan State University in St. 
Paul approved a Master's degree ADHP program that is anticipated to 
accept its first class in mid-2009. Additionally, Minnesota is the 
first state to consider legislation to facilitate the expanded scope of 
practice for the Advanced Dental Hygiene Practitioner. Legislation was 
introduced in both the Minnesota state House and Senate in mid-February 
2008 and is supported not only by the dental hygiene community, but 
also by a number of state healthcare stakeholders and dentists. A 
legislative compromise, supported by the Minnesota Dental Association, 
was reached in May 2008 which established the need for a mid-level 
provider in state statute and established a baseline scope of practice 
that nearly mirrors the clinical services outlined in the ADHP 
competencies. As a result of the compromise, a workgroup will convene 
in mid-2008 to further define the educational and licensure 
requirements for the new provider, known as the Oral Health 
Practitioner.
    As the April 2004 ``Report to the Secretary: Rural Health and Human 
Services Issues'' found, ``oral health has been described as one of the 
single greatest unmet healthcare needs in the United States. The Report 
also finds that ``in rural areas that face acute and growing dentist 
shortages, some form of alternative provider model may be particularly 
useful as a means to extend basic dental demonstrations to evaluate the 
viability and efficacy of models.''
    ADHA urges this Subcommittee and all Members of Congress to shape a 
future in which oral health services will be readily available to 
children and other vulnerable Americans who need them. Facilitating 
better utilization of dental hygienists through the establishment of 
the Advanced Dental Hygiene Practitioner is a vital part of this 
future.
Additional Support for Improving Access to Dental Care through 
        Exploration of the ADHP
    The National Dental Association included support to ``expand the 
role of the dental hygienist as the Advanced Dental Hygiene 
Practitioner in underserved areas'' in its Access to Care statement.
    The American Public Health Association Oral Health Section also 
supports the Advanced Dental Hygiene Practitioner concept, calling it 
``a role comparable to the Medical Nurse Practitioner,'' which 
``presents a timely and appropriate way to explore new approaches to 
delivery of oral healthcare to those populations in rural and 
underserved areas, i.e. the 25percent in whom 80percent of oral disease 
is found.''
    The National Rural Health Association determined that ``It is time 
for exploration of a new way to deliver oral health services--it is 
time to test the feasibility of an advanced dental hygiene 
practitioner--similar to the nurse practitioner but in the dental 
arena. NRHA sees great potential for the advanced dental hygiene 
practitioner to improve access to oral healthcare in rural areas.''
    The National Rural Education Association writes that ``For a child 
to be ready to learn in school, a child must be healthy and free from 
pain. One proven strategy for reaching children at high-risk for dental 
disease is providing oral health services in school-based health 
centers; another strategy is to support linkages between schools and 
dental providers in the community. Presently there is a shortage of 
dentists. We must better utilize the dental hygienist. NREA is excited 
about the prospect of an advanced dental hygiene practitioner.''
    Major media outlets are also recognizing the access to oral 
healthcare crisis Americans face and the ways in which the current 
delivery system is failing millions of Americans. In the wake of the 
tragic death of Deamonte Driver in February 2007, national attention 
has become more focused on the dangers associated with not obtaining 
oral healthcare services.
    An article from the October 11, 2007 edition of the New York Times 
stated, ``American children are dying because of a lack of access to 
healthcare. . . . There are nine million children who lack healthcare 
in the U.S. and millions more who are eligible for coverage but fall 
through the cracks for one reason or another.''
    Similar sentiments were echoed by The Washington Post in a July 13, 
2007 article, ``At the heart of this issue is a lack of understanding 
of the importance and implications of good oral healthcare--every day 
there are children who can't pay attention in school and who can't fall 
asleep at night because they have problems with their teeth.''
    On April 22, 2008 The Washington Post featured an article, 
``Brushed off no Longer: citing Gaps in Care, Hygienists are Beginning 
to Treat Patients Without Direct Supervision by Dentists,'', which 
stated that allowing dental hygienists to have a wider role in public 
health settings without direct supervision by dentists allows dentists 
to take care of more acute issues and which could in turn prevent 
``many difficult and expensive problems from developing in the first 
place.''
Medicaid and the State Children's Health Insurance Program
    Medicaid dental coverage for children is an essential benefit; 
regrettably, too few Medicaid-eligible children access dental care. 
More must be done to ensure that Medicaid-eligible children are able to 
access this essential benefit. Today, twelve states recognize dental 
hygienists as Medicaid providers of oral health services and provide 
direct reimbursement for their services. These states are: California, 
Colorado, Connecticut, Maine, Minnesota, Missouri, Montana, Nevada, New 
Mexico, Oregon, Washington, and Wisconsin. Other states should adopt 
this approach, which appropriately recognizes the experience, education 
and expertise of dental hygienists and fosters increased access to much 
needed Medicaid oral health services.
    While the profession of dental hygiene was founded in 1913 as a 
school-based profession, today the provision of dental hygiene services 
is significantly tied to the private dental office, which many patients 
are unable to access. With over 90 percent of all practicing dentists 
in the private sector, it is time to promote the provision of oral 
health services directly to Medicaid and SCHIP-eligible children at 
schools, community health centers and other public health settings by 
better utilizing the education, experience, and expertise of dental 
hygienists, who could be linked through referrals and/or teledentistry 
to dentists.
    SCHIP has extended dental coverage to millions of additional 
children who would otherwise be without dental insurance. ADHA and 
others in the dental community strongly support reauthorization of and 
adequate funding for SCHIP. As this Subcommittee well knows, although 
all states presently include dental benefits in their SCHIP program, 
dental benefits are not required to be included in the SCHIP program.
    In order to stabilize and buttress the dental component of SCHIP, 
the dental community urges (1) a federal guarantee for dental coverage 
in SCHIP; (2) development of a dental wrap-around benefit in SCHIP; (3) 
support for outreach and enrollment of all SCHIP-eligible children; and 
(4) support for a national performance measure that would provide data 
necessary to evaluate SCHIP dental benefits. Strengthening SCHIP, 
however, should not come at the expense of Medicaid. SCHIP stands on 
the shoulders of Medicaid, and any effort to erode Medicaid will 
adversely affect SCHIP.
    ADHA strongly supported the State Children's Health Insurance 
Program Reauthorization Act (CHIPRA), which included significant dental 
provisions, including a guaranteed dental benefit and a study on dental 
access and workforce that would examine the ``feasibility and 
appropriateness'' of dental mid-levels such as the ADHP. The 
association will look forward to the opportunity to work collectively 
with others in oral healthcare on future efforts to reauthorize SCHIP.
Improving the Nation's ``Oral Health IQ''
    Changing perceptions of oral health and oral disease is a 
critically important step in the movement to have the general public 
recognize oral health as an accepted component of general health. 
Indeed, the perceptions of the public, policymakers and health 
providers must be changed in order to ensure acceptance of oral health 
as an integral component of general health.
    The national oral health consciousness will not change overnight, 
but working together we can heighten the nation's ``oral health IQ.'' 
ADHA is already working to change public perceptions so that oral 
health is rightly recognized as a vital component of overall health and 
general well being. For example, ADHA has launched a public relations 
campaign to highlight the link between oral health and overall health; 
our slogan is ``Want Some Lifesaving Advice? Ask Your Dental 
Hygienist.''
    This ADHA campaign builds on the Surgeon General's report, which 
notes that signs and symptoms of many potentially life-threatening 
diseases may appear first in the head, neck and oral cavity precisely 
at a time when the conditions are most treatable. For example, dental 
hygienists are educated to conduct a head and neck examination and a 
screening for oral cancer at every visit and can advise patients of 
suspicious conditions.
Conclusion
     The American Dental Hygienists' Association appreciates this 
Subcommittee's interest in addressing healthcare disparities. The oral 
healthcare delivery system needs radical restructuring as evidenced by 
the untimely death of Deamonte Driver and national statistics that 
bring to light the systemic realities that serve as barriers to care 
for the underserved. ADHA wants to be part of a collaborative solution 
to the current problems of oral health disparities and inadequate 
access to oral health services for many Americans. ADHA firmly believes 
that exploration of the Advanced Dental Hygiene Practitioner model will 
better utilize the existing oral healthcare workforce and improve 
access to care for vulnerable populations, which in turn will work to 
ameliorate the nation's persistent oral health disparities. ADHA is 
committed to working with this Subcommittee--and all Members of 
Congress--to improve the nation's oral health, a fundamental part of 
overall health and general well-being. As lawmakers work to reform our 
nation's healthcare delivery system, please remember that the oral 
healthcare delivery system also requires reform and oral healthcare 
must be a part of the overall healthcare reform effort. Thank you for 
the opportunity to share the views of the American Dental Hygienists' 
Association.

WDC99 1577269-1.014468.0010

                                 
               Statement of American Hospital Association
``Addressing Disparities in Health and Healthcare: Issues for Reform''
    On behalf of our nearly 5,000 member hospitals, health systems and 
other healthcare organizations, and our 37,000 individual members, the 
American Hospital Association (AHA) appreciates the opportunity to 
submit this statement for the record addressing the issue of 
disparities in health and healthcare. America's hospitals take very 
seriously their charge to provide healthcare to everyone in their 
communities, regardless of race, color or creed. But there are 
challenges to meeting that mission.
BACKGROUND
    Research confirms that healthcare delivery can differ for different 
patient populations; that significant variations exist by ethnicity and 
gender; and that care provided to Black and Latino patients can differ 
from care otherwise provided and lead to poorer health outcomes. 
Healthcare providers realize that multiple factors contribute to these 
disparities, including whether a patient has health coverage and access 
to preventive medical care, different cultural norms, and whether the 
patient has a limited understanding of English.
    In fact, the Institute of Medicine's 2002 landmark report, Unequal 
Treatment: Confronting Racial and Ethnic Disparities in Care, suggests 
that disparities in care can result from both patient-related and 
provider-related factors.
WHAT THE AHA IS DOING
    Racial and ethnic disparities in health outcomes are systemic. As 
the above chart notes, they are caused not by a single factor but by a 
host of factors. Because hospitals provide care 24 hours a day, seven 
days a week to many diverse patients, hospitals must develop policies 
and systems to address all of these factors.
    To address this issue, the AHA convened in December 2007 the 
Special Advisory Group on Improving Hospital Care for Minorities. The 
group has met several times to address its charge of examining and 
providing guidance on how hospitals can help eliminate disparities in 
care. This diverse group includes national leaders representing civil 
rights organizations, hospitals, public health agencies, state and 
Federal Government, academic medicine, healthcare researchers and 
others. Their specific priority is to answer the question: How can the 
hospital field improve the care we provide to minorities and eliminate 
disparities in care?
    The group developed a consensus on specific activities that 
hospitals can undertake and identified areas where hospital executives 
should focus time, attention and resources, which would address the 
urgent need to reduce or eliminate disparities in healthcare outcomes 
while also strengthening overall operations. These are the group's 
recommendations:

      Further investment in quality improvement. A commitment 
to quality improvement by hospitals improves healthcare for all, not 
just minorities. Pay-for-performance efforts should focus on reducing 
disparities among conditions that disproportionately affect minority 
populations, such as infant mortality, diabetes, asthma, HIV, heart 
disease and cancer.
      Enhanced transparency and data collection measures. 
Gathering meaningful data in a systematic and uniform way can pinpoint 
whether and what type of disparities exist within a hospital's service 
areas. Linking these data to medical records and other patient 
information can provide hospital leaders with a compelling landscape of 
their communities--the demographics of their patients, what their 
healthcare needs are, the health outcomes that are attained, and where 
there might be gaps or disparities in health outcomes that need to be 
addressed. The Health Research and Educational Trust (HRET), an AHA 
affiliate, has developed a useful tool kit to guide hospitals through 
the process of collecting data on patients' race, ethnicity and primary 
language.
      Enhance governance. Through its Center for Healthcare 
Governance and Institute for Diversity in Health Management, the AHA is 
developing an ongoing training and board development program to expand 
the diversity of governing boards. By identifying and training 
potential minority trustees, hospitals and health systems will have a 
larger pool of qualified governance candidates. The goal is to make the 
governing body a better mirror of the community it serves.
      Greater focus on public health issues. The public health 
sector has identified several priority health issues as leading causes 
of poor health among minority groups--smoking, alcohol and drug abuse, 
obesity and poor nutrition and lack of exercise among them. For many 
people in lower socio-economic areas, these lifestyle management issues 
pose just as much a risk as a genetic predisposition to heart disease, 
diabetes or other chronic conditions. Hospitals can work with groups 
that focus on mitigating these risk factors.
      Improve connections with communities and populations 
within service areas. Use established organizations such as community-
based ethnic organizations, the YMCA, churches, colleges and others as 
partners in promoting health. Hospitals and healthcare systems should 
develop and sustain relationships with civil rights organizations, 
local outreach groups, networks and others, to determine specifically 
how the healthcare provider and community organizations can work 
together for the benefit of the community.
      Enhance wellness and prevention outreach efforts among 
uninsured patients. Reducing the number of acute healthcare episodes 
among uninsured patients, thereby improving their overall health, is 
essential. Helping connect uninsured patients with coverage and care 
options can ensure that they have continued access to healthcare 
services.
      Enhance healthcare workforce opportunities. Creating 
recruitment opportunities for minority populations not only can offer 
healthcare-related training, it also can generate a clinically and 
culturally proficient workforce that mirrors the community it serves.

    By focusing on these factors, hospital leaders can help improve 
outcomes not just for minority patients, but for all patients.
WHAT HOSPITALS ARE DOING
    Addressing disparities in care is not new to America's hospitals. 
Hospitals around the country have identified healthcare needs within 
their communities, determined how to address them, and dramatically 
improved the health of their minority patient populations. For example:

      The Cambridge Health Alliance in Boston, Massachusetts, 
created the Volunteer Health Advisor Program (VHA) in 2001. This is a 
volunteer-driven program that provides multicultural and multilingual 
health education and outreach to the communities in the Boston area, 
all in an effort to improve community health status. In 2007, the VHA 
staff and more than 200 volunteers offered health and wellness services 
to more than 5,500 people through 93 community events in 16 languages. 
Their outreach efforts resulted in 1,500 screenings for blood pressure, 
glucose and cholesterol levels in traditionally medically underserved 
and hard to reach minority populations.
      Adventist HealthCare System in Rockville, Maryland, 
recognized that 25 percent of the people in their service area speak a 
language other than English--part of an increasingly diverse community. 
In September 2005, the Adventist Board of Trustees appointed a blue 
ribbon panel of community leaders to develop a locally driven approach 
that addresses and eliminates healthcare disparities in all of the 
communities served by Adventist HealthCare. The panel recommended and 
the health system implemented the Adventist HealthCare Center on Health 
Disparities.

    The Center's three areas of focus are increased services for 
underserved populations; a research program to identify and promote 
best practices; and an education initiative to improve the ability of 
caregivers to provide quality care to those populations. Their efforts 
include three education modules that will foster culturally competent 
care: Health Disparities: Understanding Our Population is a discussion 
of local demographics, the definition of culturally competent care and 
a diversity training program; Stereotypes, Biases and Assumptions 
focuses on characteristics that can have an impact on patient care and 
adherence to treatments, and includes cross-cultural communication 
tools; and Health Beliefs and Practices of Different Populations helps 
caregivers incorporate differing beliefs into care and treatment plans. 
The Center also instituted patient advocacy and linguistic access 
programs, and incorporated an infrastructure for research into 
healthcare disparities that exist in their region of the Metropolitan 
Washington, D.C. area.

      Expecting Success, a national program sponsored by the 
Robert Wood Johnson Foundation, is a multi-hospital collaborative 
focused on reducing disparities in cardiovascular care. The program is 
helping 10 general acute care hospitals measure the quality of cardiac 
treatment they provide to patients based on race, ethnicity and primary 
language. For the first time, these hospitals, using the HRET data 
collection tool mentioned above, are tracking data to identify racial 
and ethnic disparities in the care they provide by focusing on the 
continuum of cardiovascular care delivered in inpatient and outpatient 
settings, and specifically care delivered to African American and 
Latino patients.

    These are just a few examples of what hospitals around the country 
are doing to eliminate healthcare disparities in their communities. 
There is a growing body of research around disparities--where it 
exists, why it exists, etc.--and the AHA is working to compile the case 
studies and best practices of these programs.
CONCLUSION
    There are several immediate steps that Congress can take to address 
disparities in care. First, safety net providers must be protected. 
These hospitals play an important role in caring for all populations, 
including minority populations in inner cities, patients in rural 
areas, and the uninsured and underinsured.
    Congress should ensure that the moratorium on proposed Medicaid 
regulations is approved, thus providing safety net hospitals with the 
resources to treat those most affected by disparities in care. If these 
regulations are implemented, it will affect coverage of rehab services 
for people with disabilities; certified public expenditures and 
intergovernmental transfers; graduate medical education; outpatient 
services; provider tax arrangements and outreach and enrollment in 
schools and specialized medical transportation to school for children 
covered by Medicaid. These budget-cutting policies proposed by the 
Centers for Medicare & Medicaid Services would have a devastating 
effect on state Medicaid programs, along with the hospitals and 
physicians that serve our nation's most vulnerable populations. Much of 
Congress has expressed opposition to these rules with bipartisan 
support.
    Congress also should support the permanent ban on self-referral to 
new physician-owned facilities, with appropriate grandfathering of 
existing facilities. The rapid proliferation of physician ownership 
must be slowed to ensure that safety-net services and the continued 
viability of full-service hospitals in communities are maintained. 
Studies have found that physician-owned limited-service hospitals have 
a devastating impact on communities by, among other effects, reducing 
patient access to specialty and trauma care at community hospitals; 
damaging the financial health of full-service hospitals that must 
maintain stand-by capacity for emergencies, even if they lose elective 
services; and ``cherry-picking'' the most profitable patients by 
avoiding low-income populations, both uninsured and Medicaid.
    In addition, as Congress considers legislation to implement value-
based purchasing, legislators should be mindful that minority 
populations often have unique and vastly different cultural and health 
needs. Standardizing delivery of care in order to measure and reward 
improvement is a laudable goal, but we must ensure that members of 
minority populations do not slip through the safety net.
    In the long term, Congress should include elimination of 
disparities in care--fair and equitable care for all--in its 
deliberations as the country seems poised to debate the future of our 
healthcare system.
    The price of poor health is high, but ensuring that disparities in 
care are eliminated, that wellness and prevention measures are 
implemented in a community-partnership mode and that America's 
hospitals continue to improve care for all can dramatically enhance our 
efforts to close the gap and eliminate disparities. Providing quality 
care to every patient is at the heart of a hospital's mission. 
Continually striving to eliminate disparities in care is a major 
priority for America's hospitals, but can only be achieved if all 
stakeholders work together for the good of patients.

                                 

    Statement of Glenn Flores, M.D., Director of the Division of 
General Pediatrics, Professor of Pediatrics and Public Health, and the 
Judith and Charles Ginsburg Chair in Pediatrics, UT Southwestern 
Medical Center and Children's Medical Center, Dallas, Texas.
    Thank you, Chairman Stark and the Ranking Member Camp, for inviting 
me to provide this written testimony on cultural and linguistic issues 
in healthcare and their importance in addressing disparities in health 
and healthcare in the United States.
    My name is Glenn Flores, M.D., and I am Director of the Division of 
General Pediatrics, Professor of Pediatrics and Public Health, and the 
Judith and Charles Ginsburg Chair in Pediatrics at the University of 
Texas Southwestern Medical Center and Children's Medical Center Dallas. 
I am a pediatrician who has cared for under-served children for 16 
years, as well as a researcher who has conducted many studies on 
racial/ethnic disparities, cultural competency, and language issues in 
health and healthcare.
    My testimony will address cultural and linguistic issues in 
healthcare, and how culturally competent healthcare is crucial in the 
reduction and elimination of disparities in health and healthcare.
Why Is Culture So Important in Healthcare?
    The world's population of 6.7 billion people inhabits 191 countries 
and speaks over 6,000 languages. In the U.S., approximately 103 million 
people (34% of the nation's population) are of non-white race/
ethnicity. By 2050, racial/ethnic minorities will comprise half of the 
U.S. population. Since 2000, minorities have comprised more than half 
of the population of the nation's 100 largest cities, and 42 of the 100 
largest U.S. cities are ``minority majority'' (defined as populations 
in which racial/ethnic minorities outnumber whites).\1\ Rapid growth in 
diversity makes it increasingly likely that healthcare providers will 
care for patients from different cultures.
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    \1\ The Brookings Institution Center on Urban and Metropolitan 
Policy. Census 2000 Matters. Racial Change in the Nation's Largest 
Cities: Evidence from the 2000 Census. Available at: http://
www.brookings.edu/es/urban/census/citygrowth.htm.
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    Mounting evidence demonstrates the profound impact culture can have 
on healthcare. Failure to consider a patient's culture can have serious 
clinical consequences, including inaccurate histories, 
miscommunication, and difficulties with informed consent; decreased 
access to care and lower likelihood of having primary care provider; 
non-adherence and decreased satisfaction with care; and less preventive 
screening, inadequate analgesia, delayed immunizations, and receipt of 
fewer prescriptions.\2\
---------------------------------------------------------------------------
    \2\ Flores G. Culture and the patient-physician relationship: 
achieving cultural competency in healthcare. Journal of Pediatrics 
2000;136:14-23.
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Normative Cultural Values
    Normative cultural values are defined as beliefs, ideas, and 
behaviors that a particular cultural group values and expects in 
interpersonal interactions. Lack of awareness of normative cultural 
values can have a profound impact on healthcare. For example, central 
to the Navajo concept of Hozhooji is the importance of thinking and 
speaking in a positive way, and the belief that thought and language 
have the power to shape reality and control events. The expectation is 
that communication between healers and patients will embody the concept 
of positive thoughts and words, and that negative thoughts and words 
can actually cause harm. A lack of awareness of hozhooji can therefore 
cause an inadequate discussion of medical risks, miscommunication about 
advanced directives, and failure to obtain informed consent. For 
example, a Navajo patient was told by a surgeon that in all operations 
there is a risk of not waking up; the patient viewed this to be a death 
sentence, so he refused to consent to having surgery. One study 
documented that 86% of Navajo patients said that advance care planning 
(establishing a living will or durable power of attorney) was a 
dangerous violation of the traditional Navajo values and thinking, and 
many would not discuss this issue because they felt it to be too 
dangerous.\3\
---------------------------------------------------------------------------
    \3\ Carrese JA, Rhodes LA. Western bioethics on the Navajo 
reservation. Benefit or harm? JAMA 1995;274:826-9.
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    Fatalismo (fatalism) is the belief that individual can do little to 
alter fate. It has been noted as a normative cultural value among 
Latinos, African-Americans, and other ethnicities and cultures. 
Fatalismo can lead to avoiding effective therapy for cancer and chronic 
diseases and less preventive screening. For example, a study of cancer 
beliefs revealed that Latinos were significantly more likely than 
whites to prefer not to know if they had incurable cancer, and to 
believe that there is little one can do to prevent getting cancer, 
having cancer is like a death sentence, and cancer is God's 
punishment.\4\
---------------------------------------------------------------------------
    \4\ Perez- Stable EJ, Sabogal F, Otero-Sabogal R, Hiatt RA, McPhee 
SJ. Misconceptions about cancer among Latinos and Anglos. JAMA 
1992;268:3219-23.
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Protective Effects of Traditional Culture and Improving the Health of 
        All Americans
    Multiple studies document that for a variety of health issues, less 
acculturation (e.g., less ``Americanization'') is associated with 
better health indicators. For example, less acculturation is associated 
with lower low birth weight rates, higher immunization rates, less teen 
depression and suicide, less cigarette smoking, less illicit drug use, 
and a significantly older age at first sexual intercourse for Latino 
girls. The reasons for this ``healthy immigrant effect'' are not yet 
completely understood, but further studies of this phenomenon hold 
potential for improving the health of all Americans.\5\
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    \5\ Flores G, Brotanek J. The healthy immigrant effect: A greater 
understanding might help us improve the health of all children. 
Archives of Pediatrics and Adolescent Medicine 2005;159:295-297.
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The Critical Impact of Language on Healthcare
    English Proficiency in the U.S.
    Fifty-five million Americans (20%) speak a language other than 
English at home, and 24 million (9%) have limited English proficiency 
(or LEP, defined as self-rating one's English-speaking ability as less 
than ``very well''). Eleven million school-age children (19%) speak a 
language other than English at home.
Adverse Consequences of Language Barriers in Healthcare
    Studies demonstrate a wide range of adverse effects that LEP can 
have on health and healthcare, including impaired health status, a 
lower likelihood of having a regular physician, lower rates of 
mammograms, pap smears, and other preventive services, non-adherence 
with medications, a greater likelihood of a diagnosis of more severe 
psychopathology and leaving the hospital against medical advice among 
psychiatric patients, a lower likelihood of being given a follow-up 
appointment after an emergency department visit, an increased risk of 
intubation among children with asthma, a greater risk of hospital 
admissions among adults, an increased risk of drug complications, 
longer medical visits, higher resource utilization for diagnostic 
testing, lower patient satisfaction, impaired patient understanding of 
diagnoses, medications, and follow-up, and medical errors and 
injuries.6,7 For example, one study found that 26% of 
mothers of Latino children cited language problems as single greatest 
barrier to healthcare, and 6% reported not bringing their child in for 
needed medical care because of language problems. LEP patients in 
psychiatric settings experience a greater likelihood of diagnosis of 
more severe psychopathology, are more likely to leave hospital against 
medical advice, are less likely to establish a good rapport with 
physician, are less likely to receive adequate explanation of 
therapeutic regimen, and are less likely to give feedback to physician.
---------------------------------------------------------------------------
    \6\ Flores G. The impact of medical interpreter services on the 
quality of healthcare: A systematic review. Medical Care Research and 
Review. 2005;62:255-299.
    \7\ Flores G, Laws MB, Mayo SJ, et al. Errors in medical 
interpretation and their potential clinical consequences in pediatric 
encounters. Pediatrics 2003;111:6-14.
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    LEP patients have a higher risk of experiencing adverse healthcare 
outcomes. For example, Mexican-American children whose parents speak 
English were found to be 12 times more likely to have a regular 
healthcare provider vs. those with LEP parents (regardless of 
insurance).\7\ Another study revealed that LEP women receive fewer 
mammograms and pap smears.\7\ Asthmatic children with LEP parents are 
three times more likely to be intubated for their asthma than those 
with English proficient parents, and monolingual Spanish-speaking 
adults with asthma whose physicians speak English are three times more 
likely to miss one or more follow-up appointments.\7\ A recent 
nationally representative survey of over 102,000 U.S. households 
revealed that children in households speaking a non-English primary 
language experience numerous disparities in medical and oral health, 
access to care, and use of services, even after adjustment for health 
and dental insurance and family income.\8\
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    \8\ Flores G, Tomany-Korman S. The language spoken at home and 
disparities in medical and dental health, access to care, and use of 
services in U.S. children. Pediatrics 2008;121;e1703-e1714.
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Patient Safety: Language Barriers, Medical Errors, and Injuries
    Research documents that language barriers can result in preventable 
medical errors and injuries. Dramatic examples in the medical 
literature include:

      A 2-year-old fractured her clavicle after falling off her 
tricycle. A resident physician misinterpreted two Spanish words, 
diagnosed child abuse, and contacted the Department of Social Services, 
who, without an interpreter, had the mother sign over custody of her 
two children. The mother did not regain custody of her children until 
48 hours later, when a medical interpreter finally was obtained.\9\
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    \9\ Flores G, Abreu M, Schwartz I, Hill M. The importance of 
language and culture in pediatric care: case studies from the Latino 
community. Journal of Pediatrics 2000;137:842-848.
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      A 10-month-old girl with iron-deficiency anemia was given 
a 13-fold overdose of iron and hospitalized for iron intoxication after 
her LEP parents were given medication instructions and a prescription 
only in English by their healthcare provider. The parents gave 15 ml of 
iron elixir (one tablespoon instead of a dropperful) based on a 
prescription label that read: ``15 mg per 0.6 ml, 1.2 ml daily.'' \10\
---------------------------------------------------------------------------
    \10\ Flores G. Language barrier. AHRQ WebM&M Morbidity and 
Mortality Rounds on the Web 2006;April. Available at: http://
www.webmm.ahrq.gov/case.aspx?caseID=123.
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      Misinterpretation of single Spanish word (``intoxicado'') 
resulted in an 18-year-old's quadriplegia after being misdiagnosed with 
a drug overdose. The patient's hematomas, brain-stem compression, and 
paralysis were actually due to a ruptured aneurysm, and the hospital 
paid $71 million in a malpractice settlement.\11\
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    \11\ Harsham P. A misinterpreted word worth $71 million. Medical 
Economics 1984;June:289-292.
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The Importance of Medical Interpreters in Healthcare
    Data indicate that medical interpreter services are often 
inadequate for millions of LEP patients in America. One study of an 
urban emergency department revealed that no interpreter was used for 
46% of LEP patients for whom an interpreter was needed, interpreters 
were not called in 1/3 of cases when both the clinician's Spanish and 
patient's English were poor, and 39% of interpreters used had no 
training. LEP patients who need but don't get interpreters are more 
likely than LEP patients who use interpreters and English proficient 
patients to have a poor or fair self-reported understanding of their 
diagnosis and treatment plan, and to wish their healthcare provider 
explained things better.
The Dangers of Medical Interpretation by Family Members, Friends, and 
        Untrained Staff
    All too often, ad hoc interpreters (including family members, 
friends, untrained medical staff, strangers pulled from the waiting 
room and the streets, and custodians) are used when language barriers 
are encountered in healthcare. The hazards of using these ad hoc 
interpreters are well documented, and include the patient being less 
likely to be told about medication side effects, and more frequent 
interpretation errors that are more likely to have actual or potential 
clinical consequences. In addition, studies show that family members 
misinterpret 23-52% of questions asked by physicians; children who 
interpret are embarrassed by and tend to ignore questions about 
menstruation, bowel movements, and other bodily functions; non-medical 
staff who interpret can exclude or distort key clinical information; 
and patient satisfaction with ad hoc interpreters is significantly 
lower than with other interpreter types.\6\
---------------------------------------------------------------------------
    \6\ Flores G. The impact of medical interpreter services on the 
quality of healthcare: A systematic review. Medical Care Research and 
Review. 2005;62:255-299.
---------------------------------------------------------------------------
    The dangers of ad hoc interpreters are dramatically illustrated in 
the following actual patient encounter that occurred in an emergency 
room and was published in the New England Journal of Medicine.\12\ A 
12-year-old boy presented to the physician with dizziness, and attempts 
to interpreter for himself and his mother:
---------------------------------------------------------------------------
    \12\ Flores G. Language barriers to healthcare in the United 
States. New England Journal of Medicine 2006;355:229-231.
 Mother: La semana pasada a el le     Last week he had a lot of dizziness
 dio mucho mareo y no tenia fiebre    and he did not have fever or
 ni nada, y la familia por parte de   anything, and his dad's family all
 papa todos padecen de diabetes.      suffer from diabetes.Doctor: Uh-humMother: A mi me da miedo porque el   I'm scared because he's dizzy,
 lo que estaba mareado, mareado,      dizzy, dizzy and he didn't have
 mareado y no tenia fiebre ni nada.   fever or anything.Doctor: Ok. So she's saying you look kind of yellow, is that what she's
 saying?Patient: Es que si me vi amarillo?   Is it that I looked yellow?
Mother: Estaba como mareado, como    You were like dizzy, like pale.
 palido.
Patient: Like I was like paralyzed, something like that.
The Many Benefits of Providing Adequate Language Services to LEP 
        Patients
    Multiple studies document the many benefits of providing trained, 
professional medical interpreter services to LEP patients.\6\ 
Interpreter services have a positive impact on preventive screening, 
including increased breast cancer screening after implementation of 
language services in clinics, and elimination of disparities between 
LEP and English-proficient patients in flu vaccinations and fecal 
occult blood testing. Interpreter services positively impact health 
outcomes. In children presenting to the emergency department, LEP 
patients with professional interpreters did not differ from English-
proficient patients in test costs or use of IV hydration, and had a 
lower likelihood of testing. LEP patients with Type 2 diabetes mellitus 
who have trained professional interpreters are two times more likely 
than English-proficient patients to receive care meeting American 
Diabetes Association guidelines, three times more likely than English-
proficient patients to have dietary consults, and did not differ from 
English-proficient patients in 18 other processes and outcomes. In 
patients with hypertension and diabetes, health status, physical 
functioning, psychological well-being, health perceptions, and pain 
scores are higher in those with language concordant vs. discordant 
physicians.
Providing Language Services to All Americans Who Need Them Would Not be 
        Costly
    In a 2002 report to Congress, the Office of Management and 
Budget\13\ estimated it would cost only a $4.04 premium per patient to 
provide interpreter services to all LEP patients needing these 
services, which is equivalent to a 0.5% increase in overall U.S. 
healthcare expenditures. This cost estimate includes coverage for LEP 
patients of interpreter services for inpatient hospitalizations, as 
well as outpatient, emergency room, and dental visits.
---------------------------------------------------------------------------
    \13\ Office of Management and Budget. Report to Congress. 
Assessment of the Total Benefits and Costs of Implementing Executive 
Order No. 13166: Improving Access to Services for Persons with Limited 
English Proficiency. Washington, D.C.: 2002.
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Ethnomedical Conditions or Folk Illnesses and Their Impact on Medical 
        Care
Folk Illnesses and Their Impact on Healthcare
    Ethnomedical conditions, or folk illnesses, are culturally 
constructed diagnostic categories commonly recognized by an ethnic 
group. The prevalence of beliefs varies tremendously, depending on 
subpopulation, region, levels of acculturation. The prevalence of 
certain folk illness beliefs, however, can be as high as 96% in certain 
Mexican-American communities. Folk illness beliefs and practices can 
affect clinical care because the symptoms often overlap with important 
biomedical conditions, the first healthcare provider contact may not be 
a physician, some folk remedies can be harmful or even fatal, and 
satisfaction with care and adherence can depend on the accepting 
response of healthcare provider
Example: How Folk Illnesses Can Affect Healthcare
    Empacho is a Latino folk illness in which food or saliva is 
believed to get ``stuck'' in the stomach because of dietary 
indiscretions such as eating the wrong foods or eating at the wrong 
time. One study\14\ found that 90% of Latino parents knew of empacho, 
and 64% said that a child in the household had suffered from it in 
past. Symptoms of empacho include vomiting, diarrhea, anorexia, 
bloating, and fever. These symptoms overlap with such biomedical 
conditions as gastroenteritis, milk allergy, formula intolerance, 
gastrointestinal obstruction, intussusception, and appendicitis. But 
the treatment of choice for empacho is not usually a physician visit. 
The most common treatments of choice among parents whose child has 
empacho include a santiguadora (a traditional healer) in 77%, home 
remedies for 58%, and doctor visits for only 37%. Only 9% of parents 
reported physicians as the initial choice for treatment, and 85% of 
those visiting physicians for empacho sought another form of therapy 
afterwards.
---------------------------------------------------------------------------
    \14\ Pachter LM, Bernstein B, Osorio A. Clinical implications of a 
folk illness: Empacho in mainland Puerto Ricans. Medical Anthropology 
1992;13:285-299.
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    Most traditional empacho treatments are harmless, and include 
dietary restriction, teas, abdominal massage with warm oil, and 
treatment by folk healers or parents. But some empacho treatments are 
harmful or even fatal. For example, Mexican-American families may treat 
empacho with powders containing high concentrations of lead (greta, 
azarcon, albayalde) whose lead content varies from 70% to 97%. Multiple 
cases of severe lead toxicity have been reported in the medical 
literature, with outcomes that include lead levels as high as 124  g/dl 
(normal is considered <10), severe lead encephalopathy, and death. The 
use of lead-based empacho remedies in certain communities can be as 
high as 35% in Mexico and 11% in U.S. Cultural competency training of 
healthcare providers that includes education about common folk 
illnesses and their treatment thus has the potential to save lives. 
There are dozens of other ethnomedical conditions that have similar 
important clinical ramifications.
Patient and Parent Beliefs and Their Impact on Healthcare
    Patient and parent beliefs are defined as a cultural group's 
beliefs about disease causality (excluding specific folk illnesses). 
Treatments associated with these beliefs include home remedies, folk 
remedies (except those used for specific folk illnesses), and over-the-
counter medications. Patient/parent beliefs can profoundly affect 
different aspects of clinical care, including prevention, therapy, and 
seeking medical care. Several home treatments for common childhood 
symptoms can result in clinical findings that can be confused with 
child abuse, and misunderstandings can lead to costly and unnecessary 
medical evaluations. In addition, certain harmful parent/patient 
beliefs and practices can cause serious morbidity and fatalities.
Lack of Awareness of Patient Beliefs Can Lead to Costly, Unnecessary 
        Medical Evaluations
    Infant head molding (the application of pressure or bindings to 
cranial bones to alter their shapes) is practiced by various Caribbean, 
Latino, European, African-American, Asian, and Native American groups, 
with the intent of promoting infants' beauty, health, or intelligence. 
The failure of healthcare providers to inquire about infant head 
molding could lead to unnecessary, expensive evaluations for such 
medical conditions as dysmorphism or craniosynostosis. Indeed, one 
study documented that none of the 30 parents interviewed told their 
child's physician that they were molding their infant's head.
Serious Morbidity and Fatalities Resulting from Harmful Cultural 
        Beliefs/Practices
    An outbreak of Gonococcal conjunctivitis occurred in Florida due to 
the use of adult urine to treat conjunctivitis in children. Serious 
Salmonella infections have been caused by use of rattlesnake meat 
capsules, powder, or jerky by Mexican-Americans to treat various 
ailments (including diarrhea, infections, AIDS, diabetes, heart 
disease, cancer). Liver injury and death from liver failure have been 
caused by a cough treatment using a tea made from the herb Senecio 
longilobus, which contains potent toxins.
Culturally Biased Attitudes and Practices and How They Can Affect 
        Healthcare
    Cultural bias in the attitudes and practices of some healthcare 
providers can have a profound impact on clinical care, including access 
to care, impaired diagnostic evaluations, lower quality of care, and 
causing and perpetuating racial/ethnic disparities in healthcare.
Provider Practices That Impair Diagnosis
    Among adolescent girls presenting to the emergency department with 
abdominal pain, race/ethnicity was found to be a significant 
determinant of whether physicians obtain sexual histories.\15\ 
Physicians significantly more often obtained sexual histories on Latino 
and African-American girls (88%) compared with whites (50%), and for 
girls <15 years old, 100% of minority girls but only 44% of white girls 
were asked about sexual activity. In a study of a white 
psychotherapists in which two case histories presented were identical 
except for race of adolescent boy (white vs. African-American), 
therapists gave significantly lower ratings of the clinical 
significance of eight of 21 pathological behaviors in the African-
American adolescent. White therapists were less concerned about the 
African-American adolescent beating his girlfriend, stealing cars, 
mistrusting the interviewer, and hating his mother. The findings 
supported the hypothesis that mental disorders in African-American 
adolescents are under-diagnosed because pathological behaviors are 
rated less severely.
---------------------------------------------------------------------------
    \15\ Hunt AD, Litt IF, Loebner M. Obtaining a sexual history from 
adolescent girls. A preliminary report of the influence of age and 
ethnicity. Journal of Adolescent Healthcare 1988 9:52-4.
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Provider Practices and Quality of Care
    Studies show providers give less pain medication to Latinos. For 
example, Latino adults presenting to an emergency room with long-bone 
fractures were found to be seven times more likely than Whites to 
receive no pain medication (after adjustment). Multiple studies also 
document that minority children are significantly less likely to 
receive known effective asthma therapies, even after adjusting for 
insurance coverage and family income.
Are These Healthcare Provider Practices Due to Inadequate Cultural 
        Competency Training?
    A study of the teaching cultural issues in U.S. and Canadian 
medical schools revealed that very few schools (8% in the U.S. and 0% 
in Canada) have separate courses on cultural issues.\16\ Eight percent 
of U.S. medical schools were found to offer no courses on cultural 
issues. In addition, few schools teach about the specific cultural 
issues of the largest minority groups in their geographic area. For 
example, only 35% of U.S. schools address the cultural issues of the 
largest minority groups in their state.
---------------------------------------------------------------------------
    \16\ Flores G, Gee D, Kastner B. The teaching of cultural issues in 
U.S. and Canadian medical schools. Academic Medicine 2000;75:451-455.
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Cultural Competency is Associated with High-Quality Patient Care
    A recent study of asthmatic children in five health plans in three 
states found that practice sites with the highest cultural competency 
scores have significantly lower patient under-use of preventive asthma 
medications and significantly better parent ratings of the quality of 
asthma care.\17\
---------------------------------------------------------------------------
    \17\ Lieu TA, Finkelstein JA, Lozano P, et al. Cultural competence 
policies and other predictors of asthma care quality for Medicaid-
insured children. Pediatrics 2004;114:e102-10.
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Summary
    Failure to consider a patients' culture can have serious clinical 
consequences. Dissatisfaction with care, miscommunication, less 
preventive screening, and failure to obtain informed consent and 
advance directives can occur when normative cultural values not 
considered. Decreased access to care, impaired health status, lower use 
of services, adverse outcomes, and medical errors and injuries are 
documented among those facing language barriers. Serious morbidity and 
fatalities have been associated with harmful folk remedies and parent 
beliefs and practices. Delayed medical care, confusion with child 
abuse, and unnecessary and costly medical evaluations are associated 
with certain parent cultural beliefs and practices. Decreased access to 
care, impaired diagnostic evaluations, lower quality of care, and 
racial/ethnic disparities are associated with biased provider 
practices. Multiple studies in the medical literature document that the 
highest quality of care is delivered when healthcare providers are able 
to effectively overcome language problems and are culturally competent.
Action Steps: Enhancing Culturally Appropriate Care and Eliminating 
        Disparities
    Action steps in five areas would substantially enhance culturally 
and linguistically care and have the potential to eliminate disparities 
in healthcare. They are as follows:
Routine Collection of Data on Race/Ethnicity, Primary Language, and 
        English Proficiency
     Healthcare institutions and health plans should routinely 
collect data on patients' self-reported race/ethnicity. Racial/ethnic 
disparities in health and healthcare cannot be monitored and eliminated 
without this essential measure.
      Healthcare institutions and health plans should routinely 
collect data for all patients on the primary language spoken at home 
and English proficiency. Such data are essential not only to monitor 
and eliminate linguistic barriers to healthcare, but also to anticipate 
the future language service needs of patients who regular access 
healthcare services and systems.
Strategies to Eliminate Language Barriers
      Provide nationwide third-party reimbursement for medical 
interpreters and other language services. Only 13 states and the 
District of Columbia currently provide third-party reimbursement for 
interpreter services, and only through Medicaid and SCHIP--not through 
Medicare or other health insurance plans. It is time for our nation to 
provide third-party reimbursement for interpreter services for all LEP 
patients.
      Increase the number of trained medical interpreters and 
their pay. Training programs and recruitment strategies need to be 
developed to take advantage of the 55 million Americans who are 
bilingual or multilingual.
      Increase the number of bilingual healthcare providers. 
This can be achieved by having medical and other health professions 
schools offer or require population-relevant foreign language 
instruction.
      Do better at teaching our children foreign languages. 
Only 44% of U.S. high-school students are currently enrolled in foreign 
language courses.
      Implement and fund more free or low-cost English classes 
to help LEP patients and families learn English. In my 16 years caring 
for underserved children and their families, I have never met a parent 
that did not want to learn English. The biggest barrier to English 
proficiency for the families that I provide care to is the lack of 
availability of free or low-cost English classes.
      Ensure comprehensive, ``door-to-door'' language access 
and services for LEP patients. Key services that often are overlooked 
include multilingual phone operators and phone trees for making 
appointments, and multilingual signage, consent forms, patient 
information materials, and prescriptions. Trained interpreters also 
need to be present throughout the medical visit (especially when 
scheduling follow-up appointments and during radiological and 
laboratory procedures).
      Enforce compliance with Title VI requirements. The Office 
of Civil Rights issued a 1998 guidance memorandum regarding the Title 
VI prohibition against national origin discrimination affecting LEP 
persons which states that denial or delay of medical care for LEP 
patients because of language barriers constitutes a form of 
discrimination, and requires recipients of Medicaid or Medicare funds 
to provide adequate language assistance to LEP patients. When all other 
options fail, legal action has been successful in enforcing compliance 
with Title VI requirements, as occurred in recent settlements with four 
New York state hospitals.\18\
---------------------------------------------------------------------------
    \18\ Office of New York State Attorney General Eliot Spitzer. 
Spitzer reaches agreement with two Brooklyn hospitals to provide 
language assistance for patients with limited English proficiency. URL: 
http://www.oag.state.ny.us/press/2003/mar/mar03a--03.html.
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      Funds and more research should be devoted to evaluating 
telemedicine options for enhancing access to language services. 
Telemedicine may prove to be highly cost-effective means for states and 
health plans to provide language access, allowing hospitals and clinics 
to quickly link to centralized bank of trained interpreters.
Strategies to Enhance Cultural Competency in Healthcare
      Cultural competency should be a standard component of 
curricula in health professions schools. Cultural competency knowledge 
and skills should be an essential part of the education of healthcare 
providers, given the substantial medical literature documenting that 
the highest quality of care and optimal patient outcomes occur when 
providers are culturally competent and are able to effectively overcome 
language problems.
      Cultural competency may need to be a requirement for 
certification of healthcare professionals and licensing of healthcare 
facilities. In 2004, the state of New Jersey enacted a law requiring 
that medical professionals be trained in the provision of culturally 
competent healthcare as a condition of licensure to practice medicine 
in NJ.\19\ As part of its state-required hospital licensure renewal 
process, Rhode Island mandates that hospitals demonstrate evidence that 
they are providing meaningful access to language services for their LEP 
patients.\20\
---------------------------------------------------------------------------
    \19\ Senate Substitute for Assembly, No. 492. State of New Jersey 
211th Legislature. Adopted March 22, 2004.
    \20\ Rhode Island General Laws Section 23-17-54; 14 090 CRIR 007 
Section 20.3. Available at: http://www.rilin.state.ri.us/statutes/
title23/23%2D17/23-17-54.HTM.
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Strategies to Reduce Healthcare Disparities through Community-Based 
        Interventions
      More federal funding should be devoted to innovative, 
community-based, culturally appropriate interventions targeting 
elimination of healthcare disparities. For example, a recent 
randomized, controlled trial was performed that resulted in the 
elimination of a healthcare disparity. This study demonstrated that, 
compared with traditional Medicaid/SCHIP outreach and enrollment, 
community-based health workers are substantially more effective in 
obtaining health insurance for Latino children, obtaining insurance 
quicker, continuously insuring children, and achieving high parental 
satisfaction with the process of obtaining insurance.\21\ To ensure 
that healthcare disparities are eliminated for all Americans, more such 
studies and programs are needed.
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    \21\ Flores G, Abreu M, Chaisson CE, et al. A randomized trial of 
the effectiveness of community-based case management in insuring 
uninsured Latino children. Pediatrics 2005;116:1433-1441.

                                 
           Statement of the National Black Nurses Association
    Mr. Chairman, I am providing a written statement for consideration 
by the Committee and for inclusion in the printed official record of 
the hearing regarding an important issue the elimination of health 
disparities. I applaud your efforts for addressing this critical matter 
facing millions of Americans.
    The National Black Nurses Association's mission is to provide a 
forum for collective action by African American nurses to 
``investigate, define and determine what the healthcare needs of 
African Americans are and to implement change to make available to 
African Americans and other minorities healthcare commensurate with 
that of the larger society''.
    Eliminating health disparities is one of the most pressing 
challenges facing the Nation on all fronts. Report upon report outline 
racial and ethnic disparities in health and healthcare. At issue are 
access, quality and accountability to culturally competent healthcare 
services. The IOM study entitled, Unequal Treatment: Confronting Racial 
and Ethnic Disparities in Healthcare, documented disparities in quality 
of healthcare that are NOT due to access-related or solely economic 
factors. It focused on disparities related to how healthcare systems 
operate, including their regulatory and legal context, and to 
discrimination. The IOM report confirmed that ``cultural and linguistic 
competence'' is essential to helping close the gaps in mortality and 
morbidity.
    Ethnic and racial disparities in healthcare have been well 
documented in recent decades across a broad range of medical 
conditions. Differences have been noted in health outcomes, which 
include quality of life, mortality, and appropriateness of care. 
Despite all that is known regarding health disparities, little 
improvement has been made, and racial and ethnic minorities continue to 
be disproportionately affected by illness and disease due in part to an 
inadequate understanding of cultural differences.
    It is our belief that we have collected enough data and that action 
should be taken now to move toward an agenda that will eliminate 
disparities. The following should be taken into consideration as 
strategies are developed.
    The 2003 ``National Healthcare Disparities Report'' developed by 
the Agency for Healthcare Research and Quality (AHRQ) offered a 
comprehensive tool to measure access and use of healthcare services by 
various populations. The NHDR provides seven key findings to 
policymakers, clinicians, health system administrators, and community 
leaders who seek to use this information to improve healthcare services 
for all populations:

    1.  Inequality in quality persists
    2.  Disparities come at a personal and societal price
    3.  Differential access may lead to disparities in quality
    4.  Opportunities to provide preventive care are frequently missed
    5.  Knowledge of why disparities exist is limited
    6.  Improvement is possible
    7.  Data limitations hinder targeted improvement efforts

    Findings in this report can help target efforts more effectively to 
improve quality and reduce disparities. In its 2005 National Healthcare 
Quality and Disparities report released on January 9, 2006, AHRQ 
reported that access to care for African Americans was narrowing. 
Improvements were observed among non-Hispanic Whites and Non-Hispanic 
Blacks relative to blood pressure control. Yet, cardiovascular disease 
is the number one killer of African Americans. Only 40 percent of those 
diagnosed with diabetes have their HbA1c under optimal control (<7 
percent). Blacks with diabetes are more likely than Whites to have 
their total cholesterol under control. Only 70 percent of those 
diagnosed with diabetes had their blood pressure under control. Rates 
of late-stage breast cancer decreased more rapidly from 1992 to 2002 
among black women (169 to 161 per 100,000 women) than among white women 
(152 to 151 per 100,000), resulting in a narrowing disparity. Yet, 
Black women had higher rates of advanced stage breast cancer than White 
women in 1992, 1993, 2002. Over 12 million children ages 2-19 years old 
are overweight, 20% are African American.
    The Behavioral Risk Factor Surveillance System (BRFSS), a random 
telephone survey conducted by state health department and the CDC; and 
the National Health and Nutrition Examination Survey (NHANES) 1999-2002 
found that Blacks had the highest prevalence of hypertension, the 
highest self-report prevalence of diagnosed diabetes and the highest 
rate of hospitalizations for stroke. The basic philosophy of this 
program was to collect data on actual behaviors, rather than on 
attitudes or knowledge, that would be especially useful for planning, 
initiating, supporting, and evaluating health promotion and disease 
prevention programs.
The Uninsured
    Over 47 million Americans are uninsured and millions lack adequate 
care. Communities of color have a higher incidence of chronic diseases, 
cardiovascular disease, diabetes, cancer, violence and HIV/AIDS, 
leading to high rates of morbidity and mortality. African Americans 
accounted for 47 percent of AIDS cases in 2005. 20 million Americans 
have diabetes; it is estimated that 20 million Americans have 
undiagnosed diabetes. 2.7 million African Americans aged 20 and older 
have diabetes. African Americans develop diabetes at 1.6 times the rate 
of whites. Diabetes is the leading cause of kidney failure and African 
Americans are more likely to suffer from kidney disease. According to 
the Centers for Disease Control and Prevention, the incidence of 
diabetes is expected to double by the year 2050 and healthcare costs 
associated with diabetes exceeded $132 billion in 2002.
Insurance Coverage
    Even more distressing are those individuals who have insurance 
coverage and continue to experience healthcare disparities. In a recent 
report from the Families USA Foundation it was revealed that insurance 
companies in most states are not required to provide health coverage to 
individuals with pre-existing conditions. This results in insurance 
companies refusing to pay for needed services that treat common 
conditions. Individuals are denied coverage and are left with large 
medical bills they can not pay many ending up in bankruptcy. Employer 
sponsored health coverage is the major vehicle for the purchase of 
health insurance for most people. This employee benefit is on the 
decline and coverage is out of reach for many Americans due to cost. 
According to Families USA upon completion of their 50 state surveys it 
is time for the Federal Government to step in and curb the harmful 
abuse by insurance companies. Citizens of this country are devastated 
by debilitating illness and disease they should not have to tolerate 
abuse by the insurance industry.
    Study after study provides evidence of the devastating effects on 
the quality of life of people of color due to healthcare disparities. 
The staggering statistics related to these disease states are only a 
snapshot of the continuing pain and suffering, let alone the economic 
impact that continues to plague our communities. While advances in 
prevention, diagnosis and treatment, particularly through biomedical 
research and technology, offer incredible promise for improved health 
and delivery of care, for a good number of this Nation's citizens, this 
dire state of health continues.
Demographics
    According to a recent IOM report the U.S. healthcare system is not 
prepared for the influx of baby boomers that will be entering the 
healthcare system. The current system is difficult to navigate there 
are issues with staffing ratios, mandatory overtime, bed closures and 
patient safety issues. The U.S. is experiencing a shortage of nurses, 
which are more severe in certain areas than others. The Department of 
Labor estimates that the number of vacancies for RNs will be 800,000 in 
2020.
Nursing Shortage
    The National Black Nurses Association was founded because of 
inequities in healthcare that existed. Healthcare disparities are not 
new to us. Black nurses are the pulse of the community and are 
confronted with the devastation of disparities in our communities on a 
daily basis. Out of 2.7 million nurses in the U.S., Black nurses 
represents 4.9%.
    We are faced with barriers preventing minority students from being 
admitted to and completing nursing school. We must increase the 
pipeline of minority students. We cannot close the healthcare 
disparities gap without nurses. More efforts must be focused on 
workforce diversity and ensure that all areas of the healthcare 
delivery system are reflective of the populations served. This can be 
accomplished by ensuring that cultural competence is an integral 
component of curriculums. The lack of ethnic minority representation in 
the healthcare system limits a healthcare professional's access to 
those who may be able to provide information about the cultural groups 
they represent.
    There are fundamental questions that remain unanswered that need to 
be addressed to reform the healthcare system if our Nation is to 
eliminate healthcare disparities:

      What is being done to expand health insurance coverage 
for the uninsured?
      How is the latest biomedical research and technology 
being used to help close the disparities gap?
      Why are African Americans less likely to get the 
expensive, newer treatments?
      How can more vigorous intervention research, occurring in 
clinical and community based settings, be funded to produce critical 
findings that underpin evidenced based practice?
      How will the education and training at health professions 
institutions help to improve the access, and quality of healthcare 
services to communities of color?
      What are the strategies to recruit and retain nurses and 
other health professionals to help reduce and eliminate healthcare 
disparities?
      Can a comprehensive health disparities bill like that 
introduced by Representative Elijah Cummings (D-MD) and other Members 
of Congress change our Nation's healthcare infrastructure to eliminate 
racial and ethnic healthcare disparities? Elements of such legislation 
seek to ensure quality healthcare; expand access; strengthen 
accountability; implement the IOM study recommendations; enhance the 
Office of Minority Health, Office for Civil Rights and the National 
Center on Minority Health and Health Disparities; support and empower 
communities in their efforts to eliminate health disparities; improves 
workforce diversity; reduce diseases and related complications from 
HIV/AIDS to asthma; and improve racial, ethnic and primary language 
data collection, use and monitoring.

    Thank you, Mr. Chairman, for the opportunity to present written 
testimony. The National Black Nurses Association and the 150,000 Black 
nurses we represent look forward to working with you on this issue in 
the future.

                                 
             Statement of National Business Group on Health
    The National Business Group on Health (The Business Group) commends 
the Congress for including a hearing on disparities in health and 
access to care as part of its ongoing health reform hearing series and 
thanks the Committee for the opportunity to submit this statement for 
the record.
Background:
    The Business Group, representing over 300 large employers that 
provide health coverage to more than 55 million U.S. employees, 
retirees and their families, is the nation's only non-profit, 
membership organization devoted exclusively to finding innovative and 
forward-thinking solutions to large employers' most important 
healthcare and related benefits issues. Business Group members are 
primarily Fortune 500 and large public sector employers, with 63 
members in the Fortune 100.
    Starting in 2007, the Office of Minority Health (OMH) at the U.S. 
Department of Health and Human Services and the Business Group have 
agreed to co-sponsor the National Partnership for Action for 
Eliminating Racial and Ethnic Disparities in Health (NPA); a multi-
faceted, national effort led by the OMH at the community, business, 
state, regional, and national levels.
    The goal of the partnership is to reduce racial and ethnic 
disparities in healthcare by 1) improving employers' awareness of the 
causes and consequences of disparities, and 2) changing employers' 
healthcare purchasing strategies in health insurance, wellness 
programs, etc. to reduce the impact that racial and ethnic disparities 
have on employees' and employers' health and healthcare costs.
Overall Goal:
    The National Business Group on Health supports the reduction and 
ultimate elimination of healthcare disparities among covered employees.
Problem:
    Research has shown that disparities occur regardless of insurance 
status. A difference in the quality of healthcare resulting from 
disparities received by insured populations is a problem. Simply 
providing insurance for employees does not guarantee equitable 
healthcare will be provided.
Effect on Employers:
    Aside from addressing healthcare disparities among employees 
because it is the right thing to do, employers recognize that healthy 
employees are the foundation for successful business. Improving and 
maintaining the health status of employees is essential to producing 
high-quality, goods and services, which, in turn increases shareholder 
value.
Solutions:
    The National Business Group on Health/OMH partnership has created 
the Racial/Ethnic Health Disparities Advisory Board, whose 
subcommittees consisting of members from academia, business leaders, 
and experts in the field of healthcare disparities are responsible for 
defining elements of data collection, communication and the business 
case for addressing healthcare disparities.
    Appropriate collection and utilization of racial and ethnic data to 
close the gaps in healthcare disparities is essential. Additionally, 
communicating data findings and health messages are key factors to 
reduce disparities. The Racial/Ethnic Health Disparities Advisory Board 
will be presenting strategies for addressing both of these factors to 
employers with an updated Analysis Paper of the business case for why 
employers should address healthcare disparities among their employees. 
We also support the current efforts of Congress to improve the ongoing 
data collection, measurement, and evaluation of healthcare disparities 
by the Federal Government.
    A current survey by a Business Group member company found that 
employers are collecting race and ethnicity data as required under law 
and using this data to actively measure quality. Another Business Group 
member is using race and ethnicity data as evidence of corporate 
responsibility to its investors,\1\ while others are using this data to 
highlight, and promote the diversity of their 
workforces.\2,3\
---------------------------------------------------------------------------
    \1\ General Motors. 2005/06 Corporate Responsibility Report. 2006. 
Available at http://www.gm.com/corporate/responsibility/reports/06/
700--social/700--na.html#minhourly; Verizon. Press Kits: Work Force 
Development. 2007. Available at  http://newscenter.verizon.com/kit/
diversity/workforce.html
    \2\ Wal-Mart. Employment and Diversity Fact Sheets. 2008. Available 
at  http://www.walmartfacts.com/FactSheets/
    \3\ IBM. Workforce Diversity. Government Requirements. 2004. 
Available at  http://www.ibm.com/ibm/responsibility/people/diversity/
government-requirements.shtml.
---------------------------------------------------------------------------
    The National Committee for Quality Assurance (NCQA) is also leading 
efforts to reduce healthcare disparities through the Recognizing 
Innovation in Multicultural Healthcare award program to publicly 
recognize health plans that have implemented initiatives to ensure 
culturally and linguistically appropriate services and reduce 
healthcare disparities. In addition, the Health Research & Educational 
Trust has created a healthcare disparities toolkit with information on 
how to collect racial/ethnic data and how to use this data.
    Again, the Business Group appreciates the opportunity to submit 
this statement for the record. As one of the largest purchasers of 
healthcare, large employers are often the driving force to change and 
improve our nation's healthcare system and can play a key role in the 
elimination of healthcare disparities. The National Business Group on 
Health looks forward to working with Members of the committee, the 
Congress and to continuing our existing partnership and collaboration 
with OMH to address the role of large employers in eliminating 
healthcare disparities and their repercussions on the health and well 
being of the American workforce.

                                 
          Statement of National Council of Urban Indian Health
    Introduction: On behalf of the National Council of Urban Indian 
Health (NCUIH), our 36 member clinics, and the 150,000 American Indian/
Alaska Native patients that we serve annually, I would like to thank 
the Health Subcommittee for this opportunity to submit testimony on 
``Addressing Disparities in Health and Healthcare: Issues for Reform.'' 
The Native American community suffers the highest rates of health 
disparities of any minority group. Moreover, Congress has repeatedly 
recognized over the decades the staggering health disparities suffered 
by the First Americans. Congress was first horrified into action by 
these health disparities in 1927 when Congress passed the Snyder Act. 
In 1976 Congress renewed their dedication to end these disparities with 
the Indian Healthcare Improvement Act, and again in 1986 and in 1992. 
Now the Native American community waits for the House of 
Representatives to again renew their pledge to eradicate the alarming 
health disparities suffered by the Native American Community by passing 
H.R. 1328, the reauthorization of the Indian Healthcare Improvement 
Act. With all the legislation passed one would think that the health 
disparities and barriers to access suffered by American Indians and 
Alaska Natives would have been ended or at least ameliorated and yet 
these disparities persist.
    Current Health Disparities Levels: Native Americans continue to 
face the highest levels of health disparities for all races combined. 
The infant mortality rate is 150% greater for Native Americans than 
that of Caucasian infants.\1\ For a quick comparison, the rate of 
Sudden Infant Death Syndrome for Native American infants is the same as 
for infants in Haiti. American Indians and Alaska Natives are 2.6 times 
more likely to be diagnosed with diabetes than the general 
population.\2\ Native Americans suffer higher mortality rates due to 
``accidents (38% higher than the general population rate), chronic 
liver disease and cirrhosis (126% higher), and diabetes (54% higher).'' 
\3\ Native peoples ages 15 to 34 constitute 64% of all suicides 
nationwide. American Indians and Alaska Natives are only 1% of the 
general population.\4\ As a recent example, in the past 12 months there 
have been 213 suicide attempts on the Rosebud Sioux reservation. That 
is at least one suicide attempt a day. Alcohol-related deaths in 
general were 178% higher than the rate for all races combined.\5\ 
Native Americans also have the fastest transition between diagnosis and 
death for HIV/AIDs and most forms of cancer.\6\ Urban Indians share 
fully these health disparities as the 2000 U.S. Census found that over 
60% of self-identified Native Americans live in urban areas.
---------------------------------------------------------------------------
    \1\ Trends in Indian Health 2000-2001, Indian Health Service, 2002.
    \2\ Indian Healthcare Improvement Act Fact Sheet, National Indian 
Health Board, 2008. See also, Unnatural Causes: Is Inequality Making Us 
Sick? PBS Documentary, 2008.
    \3\ The Health Status of Urban American Indians and Alaska Natives, 
Urban Indian Health Institute, 2004.
    \4\ 2006 National Survey on Drug Use and Health: National Findings
    \5\ ibid
    \6\ fn 1.
---------------------------------------------------------------------------
    These health disparities are the direct result of continuing social 
and economic inequality that lead to disparities in healthcare 
accessibility. The idea that health disparities are the direct result 
of health inequality is not a new idea\7\ and in the Native American 
community its existence is well documented.\8\ Lifting the Native 
American community out of the abyss of inequalities that impact their 
health and dramatically shorten their life requires Congress to stand 
by the treaty promises and the passed legislation. It requires 
addressing the chronic underfunding of IHS programs, the lack of 
culturally competent providers, and the poor social determinants of 
health. The following testimony will address each of these problems 
from the urban Indian provider prospective.
---------------------------------------------------------------------------
    \7\ See Reducing Health Disparities, presentation by Dennis 
Raphael, PhD Dec 14th, 2006 http://video.google.com/videoplay?docid=-
4129139685624192201&hl=en last accessed 6/23/2008.
    \8\ fn 2.
---------------------------------------------------------------------------
    Lack of Funding: As this Subcommittee knows the Urban Indian Health 
Program has been under sustained attack from the Administration. The 
UIHP has been zeroed out of the President's proposed budget for FY 
2009. This is the third attempt by the Bush Administration to eradicate 
the Urban Indian Health Program under the false assumption that the 
UIHP provides duplicitous services. This assumption not only ignores 
the trust responsibility of the Federal Government to provide 
healthcare to Native Americans regardless of where they reside\9\, it 
also ignores the health inequalities suffered by AI/AN. Zeroing out the 
UIHP program would have a devastating impact not only on the 36 urban 
Indian clinics dedicated to serving urban Indians, it would also be 
extremely damaging to the Tribes as they would be the ones absorbing 
the nearly 200,000 patients served annually.
---------------------------------------------------------------------------
    \9\ Senate Report 100-508, Indian Healthcare Amendments of 1987, 
Sept. 14, 1988, p. 25.
---------------------------------------------------------------------------
     Fortuitously for the UIHP, Congress vehemently disagrees with the 
Administration's views and has rejected each and every attempt by the 
Administration to kill the program.\10\ However, constantly fighting 
for even baseline funding necessary to maintain the clinics limits the 
UIHPs ability to expand services to meet the growing needs of the 
patient population--a population that is itself rapidly growing. 
Although urban Indian health clinics are able to leverage two non-IHS 
dollars for every IHS dollar received--making a program a very sound 
investment--the constant threat of elimination from the Bush 
Administration places the 36 clinics in a difficult situation. Clinics 
report that it is difficult to obtain necessary loans for facilities 
repair and expansion, that they have problems recruiting and retaining 
necessary personal, and that they are unable to expand programs needed 
by their patient population. Urban Indian health clinics have done 
impressive things with limited resources from significantly reducing 
the rates of diabetes in their patient populations to decreasing 
suicide attempts and relapse of addictive behaviors. However, these 
services are only the bare minimum of what the patient population needs 
and what the Urban Indian Health Program could provide if time, energy, 
and resources were not constantly drained by the need to fight the 
Administration's attack on the program's very existence.
---------------------------------------------------------------------------
    \10\ See House Report 109-46, House Report 110-187, and Senate 
Report 109-275.
---------------------------------------------------------------------------
     It is difficult to determine whether or not the urban Indian 
health clinics reside in areas that follow the so-called 80-20 rule, 
which says that 80% of the medical costs for an area are driven by 20% 
of the population because the urban Indian population tends to be 
highly fluid, transitioning between reservation and urban centers with 
increasing frequency.\11\ The UIHP does not have the funds to do an 
appropriate needs assessment study of this shifting population to even 
determine what needs are driving the costs. There hasn't been a needs 
assessment done for the urban Indian population since the early 1980s. 
The most recent estimates done by the Indian Health Service suggests 
that the urban Indian clinics are currently funded at 22% of the need, 
and that was the need rates calculated in 1981.
---------------------------------------------------------------------------
    \11\ ``[The] patterns of cross or circular migration on and off the 
reservations make it misleading to suggest that reservations and urban 
Indians are two well-defined groups,'' United States v. Raszkiewicz, 
169 F.3w 459, 465--7th Cir. 1999.
---------------------------------------------------------------------------
     The most recent regulations promulgated by the Centers for 
Medicaid and Medicare services are also badly damaging to the financial 
security of the Urban Indian Health Program. As will be discussed in a 
later section, nearly one in four Indians living in urban centers live 
in poverty and nearly half live below the 200% of the Federal poverty 
level.\12\ This means that the UIHP sees a high number of Medicaid 
patients. The patients are often what are classified as `complex 
patients' meaning they suffer from chronic disease, and often multiple, 
co-morbid, chronic diseases.\13\ The regulations on case-management and 
outpatient hospital services significantly undercut the financial 
stability of many urban Indian health clinics as States' limit services 
available in their State Medicaid plans.\14\ Urban Indian health 
clinics are better able to weather the damage of these regulations than 
many other clinics, assuming that their base funding through IHS 
continues and is no longer under attack. However, the combined impact 
of these regulations and the attack on the UIHP funding by the 
Administration, if both are successful, would mean the complete 
shutdown of nearly all 36 clinics across the country, leaving the UIPH 
potential patient population of 939,588 Native Americans without 
primary care.
---------------------------------------------------------------------------
    \12\ fn 3.
    \13\ The general trifecta of chronic disease suffered by urban 
Indians is diabetes, heart disease, and hypertension. These three 
disease reinforce the symptoms and debilitating impact of the others. 
Fn 3.
    \14\ See generally The Administration's Medicaid Regulations: 
State-by-State Impacts. Committee on Oversight and Reform, March 2008.
---------------------------------------------------------------------------
Recommendations:
      Restoration of the Urban Indian Health Program in the FY 
2009 Budget, and continued funding of the program.\15\
---------------------------------------------------------------------------
    \15\ The suggested restoration level for UIHP in the FY 2009 budget 
is 40 million. Views and Estimates. Senate Committee on Indian Affairs. 
Febuary 2008.
---------------------------------------------------------------------------
      Repeal of the CMS regulations related to case management 
services\16\ and redefinition of Medicaid outpatient hospital 
services.\17\
---------------------------------------------------------------------------
    \16\ The case management regulation was published December 4, 2007 
at 72 Federal Register 68007.
    \17\ The redefinition of outpatient hospital services was published 
September 22, 2008 at 73 Federal Register 9685.
---------------------------------------------------------------------------
      Appropriate funds to conduct a full needs assessment for 
the urban Indian community.

    Culturally Competent Care: One of the single largest barriers to 
care, and largest reasons for continuing health inequality, is the lack 
of culturally competent care available to not just Native Americans, 
but all minorities. Patients treated without necessary cultural 
sensitivity and understanding suffer worse health outcomes, are more 
likely to have a relapse, and more likely to have a serious medical 
crisis.\18\ Culturally competent care is not a luxury, but a necessity 
if we are going to be serious about reducing the health disparities and 
health inequality faced by all minorities.
---------------------------------------------------------------------------
    \18\ See fn 1.
---------------------------------------------------------------------------
    Cultural competency for Native Americans means the provider must 
not only be aware of the larger historical and cultural context of the 
patient, but also be aware of the specific culture of that patient's 
tribe. Each tribe has its own language and belief systems, which forms 
the structure of values within which the provider must be able to speak 
in order to achieve good health outcomes. Native American patients have 
a greater tendency to distrust non-Native providers as their history is 
replete with instances where the health provider has actually been the 
deliverer of illness and ultimately death.\19\ Providers, when dealing 
with Native American patients, have consistently found that placing the 
needs of the patient in the framework of family needs and 
responsibilities, as opposed to individual needs, leads to greater 
compliance health and medicine regimens.\20\
---------------------------------------------------------------------------
    \19\ Broken Promises: Evaluating the Native American Healthcare 
System. Civil Rights Commission. 2004
    \20\ Invisible Tribes: Urban Indians and Their Health in a Changing 
Worlds. Urban Indian Health Commission. 2007
---------------------------------------------------------------------------
     Culturally competent care is one of the major reasons that the 
Urban Indian Health Program can not seriously be considered duplicitous 
with other Federal programs such as the Community Health Centers.\21\ 
The Urban Indian Health Program is currently the only source of 
culturally sensitive care for Native Americans living in urban centers. 
However, the UIHP, like IHS as a whole, has difficulty finding 
healthcare providers with the appropriate cultural knowledge. The 
growing lack of primary care providers from obstetricians to RNs is 
well documented. What has not been well documented, or even 
significantly explored, is the lack of culturally competent health 
providers. Only recently have there been serious discussion regarding 
paying for on-the-job training in cultural competency within CMS.\22\ 
More important, from the perspective of NCUIH, are programs that 
encourage Native Americans and minorities to enter into the health 
professions. Not only enter into the health professions, but return to 
their communities to provider care.
---------------------------------------------------------------------------
    \21\ The National Association of Community Health Clinics has 
consistently supported the Urban Indian Health Program, and have 
declared in Congressional testimony and letters of support.
    \22\ There was very limited discussion regarding a potential 
payment code regarding culturally competent care.
---------------------------------------------------------------------------
     Current proposed changes by the Health Resources and Services 
Administration (HRSA) to the classification and methodology of the 
health professional shortage areas (HPSA) and medically underserved 
areas/populations (MUA/P) are concerning as it could have an damaging 
impact on rural health providers and the providers with a largely 
minority patient populations. The proposed change to the classification 
and methodology does not include a calculation for determining the 
cultural competency of the providers available. Any potential change to 
the HPSA and MUA/P classifications must also include an analysis of the 
cultural competency of the health providers of that area for the 
patient population that they serve.
Recommendations:

      Increase the number of scholarships available to minority 
students that not only encourage them to enter into the health 
profession, but to return to their communities. Programs such as the 
Indian Health Professions Scholarships (P.L. 94-437, section 104), 
Indian health Service Loan Repayment Program (P.L. 94-437, section 
108), and the Health Professions Recruitment Program for Indians (P.L. 
94-437, section 102). It is not enough to simply encourage minority 
students to enter into the health professions; there must also be a 
financially viable way for them to return to their communities.
      Include cultural competency of health providers as a 
metric for determining classifications such as HPSA and MUA/P.
      Include cultural competency as a requirement for 
government health programs and grants, such as 330 CHC grants, SAMHSA 
provider grants, and similar programs.

    Social Determinates of Health: As the health professionals become 
more alarmed at the growing and irrefutable health disparities between 
the general population and minorities, rich and poor, urban and rural, 
greater amounts of research have been dedicated to determining the 
social determinants of health. The results of this research are not 
surprising. Poverty, homelessness, social and physical isolation are 
all key indicators of health inequality. The differences between the 
general population and minorities, particularly Native Americans, in 
living conditions are directly linked in the extreme differences in 
health status. It is an enormous social injustice that those with the 
greatest living disparity also suffer the greatest health disparity. It 
is an even greater injustice when one realizes that the group living 
with the greatest disparities across the board from education, 
purchasing power parity, and health are the Native Americans.
     Urban Indians suffer greater rates of poverty, homelessness, 
unemployment, and social isolation than the general population.\23\ 
These disparities translate into health disparities that are difficult 
for any one provider, or set of providers, to seriously address.\24\ 
Rather, in order for the underlying causes of the health disparities to 
be seriously addressed there must be a comprehensive rethinking of 
Federal health and social policy towards Native Americans. The 
clustering of disadvantage--meaning Native Americans suffer 
unemployment, poverty, poor housing, and poor health outcomes all at 
once--means that there must be a coherent attempt to address those 
problems as part of the continuum of inequality as opposed to 
approaching each problem individually.
---------------------------------------------------------------------------
    \23\ See fn 3, fn 20.
    \24\ See generally fn 7.
---------------------------------------------------------------------------
    From the health provider perspective this means transitioning from 
a medical crisis model of care to a wellness model of care that 
involving dealing not only with the immediate illness but also the 
underlying social causes. This would require a shift in Federal payment 
policy for programs such as Medicare and Medicaid from incremental 
payment scale to an episodic payment plan. It would also mean a focus 
on developing a medical home for the patients rather than the current 
split between primary care, specialty care, mental health, and social 
services. Developing a medical home means employing the `medical pod' 
method organizing health professionals. These proposed changes are 
discussed below.
    The current payment method under Medicaid and Medicare, unless the 
patient is considered a `complex patient,' pays providers in 15 minute 
increments. Generally speaking those 15 minutes are `sticky,' meaning 
that Medicaid and Medicare pay an increasingly smaller percentage of 
the cost the longer the appointment takes. If a patient has been 
classified as a `complex patient,' meaning that the patient has 
multiple conditions, or a complex chronic disease, then the entire 
episode of treatment is paid for. It is a good thing that CMS has moved 
towards a complex patient code, but if we are to be serious about 
reducing health disparities we want to address chronic disease and 
illness before the patient becomes diabetic, develops heart disease or 
hypertension. The National Council of Urban Indian Health would 
encourage broadening the complex patient code to include those who are 
in the preconditions for chronic disease. It is difficult, if not 
impossible, to explain the significant life style changes that must 
happen when someone is diagnosed as pre-diabetic in order to prevent 
the onset of diabetes in a single 15 minute appointment. Changing the 
patient codes to expand the definition of complex patient would give 
providers the necessary time with their at-risk patients before they 
become patients with chronic illness.
    There has been a great deal of discussion regarding the development 
the medical home model of care within the United States. A medical home 
means that the patient receives all of their care except complex 
specialty care for advanced illness through a single provider. This 
model increases communication between the healthcare professionals 
involved in the patient's care, increases patient involvement, and 
increases compliance with the health regimen developed by the health 
professionals. When the medical pod method is employed in conjunction 
with medical home model social workers and similar professionals become 
involved in the care of patients, increasing their health outcomes. 
These professionals close the loop in patient care to ensure that the 
patient continues implementation of the health regimen outside the 
healthcare delivery setting. Social workers also bringing in the social 
aspects of health: unemployment, poverty, poor housing. Addressing 
these issues through the healthcare lens increases the likelihood the 
patient will have a good health outcome.

Recommendations:

      Broaden the definition of `complex patient' for Medicaid 
and Medicare payment codes.
      Encourage the transition to a medical home by allowing 
billing of social services and case management to Medicaid and 
Medicare.
      Encourage the use of the `medical pod' method of care.

                                 
                      Statement of Papa Ola Lokahi
    Aloha Chairman Stark and Members of the Subcommittee on Health. 
Thank you for the opportunity to provide a statement on addressing the 
on-going and increasing health disparities which our nation's 
population is experiencing. My name is Hardy Spoehr, Executive Director 
of Papa Ola Lokahi (POL), the Native Hawaiian Health Board. My comments 
will be primarily focused on health disparities in the Native Hawaiian 
population.
    Native Hawaiians, like American Indians and Alaska Natives, are 
Indigenous Peoples of the United States. The Native Hawaiian population 
comprises a little over 400,000 people with the majority still being 
resident in the State of Hawai`i. It is important to note, however, 
that today Native Hawaiians live in every state of the nation. The 2000 
Census identified:


                       Where Native Hawaiians Live           State of Hawai`i                 Number           PercentCounty of Kaua`i                        13,511          ................
City and County of Honolulu            153,117          ................
County of Hawai`i                       43,010          ................
County of Kaua`i                        30,017          ................
  Total, State of Hawai`i              239,655           61%Continental United States              ...............  ................(by HRSA Region)                       ...............  ................
Southwest Region (excluding Hawai`i)    85,754          ................
Northwest Region                        42,247          ................
Southeast Region                        18,258          ................
Northeast Region                        15,248          ................
  Total, Continental U.S.              161,507           39%    Total, Native Hawaiians            401,162          100%Source: 2000 U.S. Census

    The top ten Congressional Districts with Native Hawaiian residents 
are:
 Hawai`i--2nd District........  162,128      Washington--9th  2,521
                                             District.
Hawai`i--1st District........  77,527       Washington--6th  2,237
                                             District.
Nevada--1st District.........  3,464        California--7th  2,045
                                             District.
Nevada--3rd District.........  3,451        California--10t  1,957
                                             h District.
California--13th District....  2,972        Alaska--0        1,878
                                             District.Source: 2000 U.S. Census

Health Disparities and Native Hawaiians
    Native Hawaiians along with other Pacific Islanders are identified 
by the U.S. Census Bureau as one of six racial and/or ethnic 
populations within the United States. These designations are in federal 
statutes and Executive Branch policy directives and serve as a basis 
for relative socio-economic comparisons in the United States. These 
comparisons also influence funding levels for various federal programs 
targeting socio-economic disparities in and among the various 
populations. As a specific population, Native Hawaiians have serious 
health disparities which trace their root causes back to times of 
contact with foreigners during the 18th and 19th centuries. The 
severity of these disparities continues and have been enumerated in 
proposed reauthorization legislation for the Native Hawaiian Healthcare 
Improvement Act.
    In a study by Johnson, Oyama, and Le Marchand entitled ``Hawaiian 
Health Update'' (1998) and funded by POL, five major findings were 
identified which remain valid today:

    1.  That when reviewing the mortality trends since 1910, Native 
Hawaiians have experienced the highest mortality rates of any ethnic 
group in Hawai`i and have had among the lowest life expectancy of all 
groups in the population.
    2.  That Native Hawaiian life expectancy at birth has ranged from 
five to ten years less than the overall population average.
    3.  That Native Hawaiians have higher age-adjusted morbidity rates 
for hypertension, asthma, diabetes and heart conditions than the total 
population.
    4.  That the ``years of productive life lost'' by Native Hawaiians 
is the highest of any ethnic group in Hawai`i.
    5.  That cancer mortality rates for Native Hawaiians, particularly 
females, are among the highest in the United States. Death rates for 
Native Hawaiian women are 70% higher than for all women in Hawaii.

    The extent of health disparities is clearly evident in Hawai`i 
State health data which, it is assumed, is similar for Native Hawaiians 
living on the Continental United states.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    In general, the current status of Native Hawaiian health can be 
summarized in five major points:
    1.  There is a general lack of awareness nationally about Native 
Hawaiians and Native Hawaiian health status and related issues.
    2.  There is indifference by the general Hawai`i population to 
Native Hawaiian health.
    3.  There is a general lack of acceptance of Native Hawaiian-
specific data among federal agencies in the national arena where 
resources are allocated.
    4.  There is a general lack of cultural competency and 
understanding of Native Hawaiians in the providing of healthcare 
services, teaching and education, and in conducting research.
    5.  There is under representation of Native Hawaiians in health, 
allied-health, and research professions.

    Data is critical to determining how best to move in the future. A 
number of federal agencies have not fully implemented the reporting 
requirements mandated by Office of management and Budget in 1998 and 
continue to use an antiquated `Asian Pacific Islander' (API) or `Asian 
American Pacific Islander' (AAPI) identifier instead of the required 
disaggregated `A' (Asian), `AA' (Asian American) and `NHOPI' (Native 
Hawaiian and Other Pacific Islander) or ``NHPI'' identifiers. The 
result is that often in national health studies and reports, the 
national health status trends, or health profiles, for Native Hawaiians 
and other Pacific Islanders is not apparent because it is masked by the 
larger Asian component.
    Papa Ola Lokahi strongly recommends that the Congress reviews the 
untimely implementation of Office of Management and Budget (OMB) policy 
and clearly states that health and related data needs to be collected, 
analyzed, and reported in accordance with OMB Circulars and Directives 
including its ``revisions to the standards for classification for 
Federal data on race and ethnicity,'' dated October 30, 1997, and 
codified as 62 FR 58782-58790; its Bulletin No. 00-02 dated March 9, 
2000; its Working Group Report dated December 15, 2000; and its 
memorandum for the President's Management Council dated January 20, 
2006, entitled ``Guidance on Agency Survey and Standardized Information 
Collections.'' All of these have to do with collecting and reporting 
data specifically for Native Hawaiians and other Pacific Islanders.
    Additionally, Papa Ola Lokahi through its years of operations in 
Hawai`i and across the nation commends to the Congress its findings:

     1.  There is no ``one-size-fits-all'' model for healthcare 
delivery--each community has its own priorities and ways of doing 
things. This is applicable to Native Hawaiians living in Hawai`i and to 
Native Hawaiian and Pacific Islander communities spread across the 
Continental United States.
     2.  The health programs that are working in Native Hawaiian 
communities need to be highlighted, replicated and built upon for 
continued success.
     3.  Traditional Native Hawaiian healing and spirituality must be 
integral components of any major effort to address Native Hawaiian 
health.
     4.  Research must be respectful of Native Hawaiian ways and 
customs.
     5.  Disease prevention focused on individual responsibility needs 
to be emphasized in any health program.
     6.  Physicians, more specifically Native Hawaiian physicians, need 
to be involved in program development and community interventions.
     7.  Native Hawaiians who participate in data collection and 
analysis feel they are part of making the Native Hawaiian community as 
a whole healthier.
     8.  When working with Native Hawaiian individuals, health 
providers need to utilize the strengths of the family--a multi-
generational approach.
     9.  Service providers working in Native Hawaiian communities need 
to utilize mentors and role models to educate communities and 
professionals alike.
    10.  The academic approach to research is often incompatible with 
Native Hawaiian community approaches and desires.
    11.  A major effort needs to continue to increase the number of 
Native Hawaiian health researchers and health and allied-health 
professionals.
    12.  An Institutional Review Board (IRB) model controlled by the 
community in which research is being conducted is an excellent model 
and tool for monitoring research and ensuring that there is a definable 
community benefit.

    Mahalo for the opportunity to provide these thoughts for 
consideration.

                                 
              Statement of Special Olympics International
Testimony on Behalf of Special Olympics
     As Senior Vice President of Special Olympics International, I, 
Stephen B. Corbin, submit this written testimony on behalf of Special 
Olympics International, to the record of the U.S. House of 
Representatives, Committee on Ways and Means, Subcommittee on Health's 
hearing of June 10, 2008, ``Addressing Disparities in Health and 
Healthcare: Issues for Reform.'' Special Olympics provides year-round 
sports training and athletic competition in a variety of Olympic-type 
sports for children and adults with intellectual disabilities, giving 
them continuing opportunities to develop physical fitness, demonstrate 
courage, experience joy and participate in a sharing of gifts, skills 
and friendship with their families, other Special Olympics' athletes 
and the community. Last year, almost 550,000 athletes with intellectual 
disabilities participated in 20,000 sports competitions across the 
United States--an average of almost 28 events per day. What began as a 
sports movement for individuals with intellectual disabilities has 
evolved into a worldwide movement to improve the health and quality of 
life of individuals with intellectual disabilities through sports 
competition and related programs such as our Healthy Athletes Program.
    Health issues are of particular concern for those we serve. Like 
race, ethnic origin, and gender, intellectual disabilities are a life-
long phenomenon accompanied by significant health disparities across 
the lifespan. Similarly, like other members of groups who face health 
inequity and health disparities, both access to healthcare and quality 
healthcare are significant issues for individuals with intellectual 
disabilities. For example, only 1 in 50 primary care physicians has 
received clinical training to qualify to properly treat the more than 6 
million individuals with intellectual disabilities in the United 
States. Complicating the matter further, there is no reliable source 
for people with intellectual disabilities and their families to find 
qualified healthcare providers who are willing to treat their special 
needs. Few health practitioners want to ``deal'' with individuals with 
intellectual disabilities. As a result, when they are able to find 
healthcare providers willing to see them, the quality of care provided 
to people with intellectual disabilities is often inferior and 
inconsistent.
    Our research shows that individuals with intellectual disabilities 
in the United States have poorer health, more specialized healthcare 
needs, and greater difficulty accessing healthcare services and 
doctors. For example, in 2006, at the U.S. National Games in Iowa, 1337 
Special Olympic Athletes were screened through our Healthy Athletes 
program. More than 53% of our athletes failed hearing tests. Almost 50% 
failed vision screenings and were given prescription glasses onsite. 
Twenty-three percent (23%) were overweight in addition to the 36% who 
were obese. More than 20% had untreated tooth decay and 38% had 
diseases of the gums. Some 34% had osteoporosis screenings that 
indicated a need for further examination.
     Though routinely denied access to healthcare, the population of 
individuals with intellectual disabilities is excluded from current 
policies that cover the ``medically underserved'' in the Health 
Resources and Services Administration (HRSA), the National Institutes 
of Health (NIH), and other United States Government programs. 
Individuals with disabilities are not only underserved, they are ill-
served. They do not even receive the same benefits, research dollars, 
and government attention as other individuals who face disparate 
treatment based on race, gender, and ethnic origin.
     Special Olympics has documented that health equity and health 
status disparities are significant issues for individuals with 
intellectual disabilities. This Committee can have a dramatic impact as 
it seeks ways to address disparities in health and healthcare and looks 
at health disparities as an issue for future healthcare reform. We urge 
the Committee to: include individuals with intellectual disabilities 
amongst those with documented disparities in health and access to 
healthcare; include them amongst the ``medically underserved;'' and 
include the health and healthcare needs of individuals with 
intellectual disabilities in discussions of all aspects of health 
disparities.

                                  
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