[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
57-416 PDF
2008__
2008
H.R. 3014, HEALTH EQUITY AND ACCOUNTABILITY ACT OF 2007
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
TUESDAY, JUNE 24, 2008
__________
Serial No. 110-132
Printed for the use of the Committee on Energy and Commerce
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COMMITTEE ON ENERGY AND COMMERCE
JOHN D. DINGELL, Michigan, JOE BARTON, Texas
Chairman Ranking Member
HENRY A. WAXMAN, California RALPH M. HALL, Texas
EDWARD J. MARKEY, Massachusetts FRED UPTON, Michigan
RICK BOUCHER, Virginia CLIFF STEARNS, Florida
EDOLPHUS TOWNS, New York NATHAN DEAL, Georgia
FRANK PALLONE, Jr., New Jersey ED WHITFIELD, Kentucky
BART GORDON, Tennessee BARBARA CUBIN, Wyoming
BOBBY L. RUSH, Illinois JOHN SHIMKUS, Illinois
ANNA G. ESHOO, California HEATHER WILSON, New Mexico
BART STUPAK, Michigan JOHN SHADEGG, Arizona
ELIOT L. ENGEL, New York CHARLES W. ``CHIP'' PICKERING,
GENE GREEN, Texas Mississippi
DIANA DeGETTE, Colorado VITO FOSSELLA, New York
Vice Chair ROY BLUNT, Missouri
LOIS CAPPS, California STEVE BUYER, Indiana
MIKE DOYLE, Pennsylvania GEORGE RADANOVICH, California
JANE HARMAN, California JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine MARY BONO MACK, California
JAN SCHAKOWSKY, Illinois GREG WALDEN, Oregon
HILDA L. SOLIS, California LEE TERRY, Nebraska
CHARLES A. GONZALEZ, Texas MIKE FERGUSON, New Jersey
JAY INSLEE, Washington MIKE ROGERS, Michigan
TAMMY BALDWIN, Wisconsin SUE WILKINS MYRICK, North Carolina
MIKE ROSS, Arkansas JOHN SULLIVAN, Oklahoma
DARLENE HOOLEY, Oregon TIM MURPHY, Pennsylvania
ANTHONY D. WEINER, New York MICHAEL C. BURGESS, Texas
JIM MATHESON, Utah MARSHA BLACKBURN, Tennessee
G.K. BUTTERFIELD, North Carolina
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
DORIS O. MATSUI, California
_________________________________________________________________
Professional Staff
Dennis B. Fitzgibbons, Chief of
Staff
Gregg A. Rothschild, Chief Counsel
Sharon E. Davis, Chief Clerk
David Cavicke, Minority Staff
Director
(ii)
Subcommittee on Health
FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York Ranking Member
BART GORDON, Tennessee RALPH M. HALL, Texas
ANNA G. ESHOO, California BARBARA CUBIN, Wyoming
GENE GREEN, Texas HEATHER WILSON, New Mexico
DIANA DeGETTE, Colorado JOHN B. SHADEGG, Arizona
LOIS CAPPS, California STEVE BUYER, Indiana
Vice Chair JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex
officio)
C O N T E N T S
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Page
Hon. Lois Capps, a Representative in Congress from the State of
New Jersey, opening statement.................................. 1
Hon. Hilda L. Solis, a Representative in Congress from the State
of California, opening statement............................... 2
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, prepared statement......................... 4
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 5
Hon. John D. Dingell, a Representative in Congress from the State
of Michigan, opening statement................................. 6
Hon. Tammy Baldwin, a Representative in Congress from the State
of Wisconsin, opening statement................................ 7
Hon. Jan Schakowsky, a Representative in Congress from the State
of Illinois, opening statement................................. 8
Hon. Edolphus Towns, a Representative in Congress from the State
of New York, prepared statement................................ 9
Hon. Frank Pallone, a Representative in Congress from the State
of New Jersey, prepared statement.............................. 150
Witnesses
Hon. James E. Clyburn, a Representative in Congress from the
State of South Carolina........................................ 9
Prepared statement........................................... 10
Hon. Jerry Moran, a Representative in Congress from the State of
Kansas......................................................... 12
Prepared statement........................................... 14
John Ruffin, Ph.D., Director, National Center on Minority Health
and Health Disparities, National Institutes of Health,
Department of Health and Human Services........................ 16
Prepared statement........................................... 18
Garth Graham, M.D., M.P.H., Deputy Assistant Secretary for
Minority Health, Office of Public Health and Science Office of
the Assistant Secretary for Health, Department of Health and
Human Services................................................. 26
Prepared statement........................................... 28
Risa Lavizzo-Mourey, M.D., M.B.A., President and Chief Executive
Officer, Robert Wood Johnson Foundation........................ 48
Prepared statement........................................... 51
James R. Edwards, Jr., Adjunct Fellow, Hudson Institute.......... 59
Prepared statement........................................... 60
Mohammad N. Akhter, M.D., M.P.H., Executive Director, National
Medical Association............................................ 63
Prepared statement........................................... 65
Sally Satel, M.D., American Enterprise Institute................. 70
Prepared statement........................................... 71
Theodore Knatt, M.D., Greater Baton Rouge Musculoskeletal Group.. 74
Prepared statement........................................... 76
Janet Murguia, J.D., President and Chief Executive Officer,
National Council of La Raza.................................... 80
Prepared statement........................................... 82
Bruce Lesley, President, First Focus............................. 90
Prepared statement........................................... 92
Response to submitted questions for the record............... 193
Deeana Jang, J.D., Policy Director, Asian and Pacific Islander
American Health Forum.......................................... 98
Prepared statement........................................... 100
Submitted Material
The TriCaucus, letter of May 21, 2008 to Messrs. Dingell and
Pallone........................................................ 127
Local, state and national organizations, letter of April 25, 2008
to Messrs. Dingell and Pallone................................. 130
Hon. Donna M. Christensen, prepared statement.................... 138
Hon. Mike Honda, prepared statement.............................. 146
The AdMeTech Foundation, prepared statement...................... 148
Close the Gap, a Boston Scientific initiative, prepared statement 152
Kaiser Permanente, prepared statement............................ 157
``Health care is high on mayor's agenda,'' The Times-Picayune,
June 5, 2008................................................... 160
''Lifeline to Health Equity: Policies for Real Health Care
Reform,'' a report by Brian Smedley for the Service Employees
International Union and the National Conference of Black Mayors 161
.................................................................
H.R. 3014, HEALTH EQUITY AND ACCOUNTABILITY ACT OF 2007
----------
TUESDAY, JUNE 24, 2008
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:08 a.m., in
room 2322 of the Rayburn House Office Building, Hon. Frank
Pallone, Jr. (chairman) presiding.
Members present: Representatives Pallone, Towns, Green,
Capps, Baldwin, Schakowsky, Solis, Dingell (ex officio), Deal,
Blackburn, and Barton (ex officio).
Staff present: Melissa Sidman, Virgil Miller, Brandon
Clark, Brin Frazier, Lauren Bloomberg, Chad Grant, Ryan Long,
and Jeanne Ireland.
OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NEW JERSEY
Ms. Capps [presiding]. This hearing will come to order.
This is the Health Subcommittee hearing on House Resolution
3014, the Health Equity and Accountability Act. My name is Lois
Capps. I am Vice Chair of the Health Subcommittee, acting in
the absence of Mr. Pallone, who is on the floor discussing
Medicare, and I am very honored indeed to welcome our honorable
first panel of witnesses, two colleagues in Congress, who will
be giving their testimony shortly: the Honorable Mr. Clyburn
and the Honorable Mr. Moran.
I want to acknowledge, we also have been joined by the
Delegate from the Virgin Islands, Donna Christensen, who is
Chair of the Health Task Force for the Congressional Black
Caucus.
So, without further ado, welcome everyone. As I mentioned,
today's hearing is on Health Equity and Accountability Act
introduced by my good friend Hilda Solis. H.R. 3014 has
tremendous support from the Tri-caucus, as well as several
members of this committee, including myself. The legislation
seeks to address the glaring health disparities that exist in
our Nation among different racial and ethnic communities and
also amongst different geographical groups. I think that we
need this bill more than ever. I am constantly dismayed,
actually horrified to learn how far the United States lags
behind other industrialized countries in terms of maternal and
infant mortality rates, as well as other quality of life
measures. And upon investigating these statistics, we learn
that they are often caused by the disparities that exist here,
right here in our own country.
Why is it that the maternal mortality rate among black
women in America is four times that of non-Hispanic white
women? Why is it that Hispanics are nearly twice as likely to
die from diabetes as non-Hispanic white people? The Institute
of Medicine found that these disparities persist even when
controlled for socioeconomic factors, and H.R. 3014 does an
excellent job of addressing the reasons why these disparities
persist and how we should go about fixing them.
For too many, the lack of access to healthcare,
specifically culturally competent healthcare, is what is
driving these disparities. So H.R. 3014 addresses them by doing
at least three things, which I will mention: improving access
to healthcare services; second, improving health work force
disparities, diversity, that is to have the culturally and
significant competencies among staff who are caring for those
with different cultural backgrounds; and third, bolstering
efforts to ensure culturally and linguistically appropriate
healthcare.
Furthermore, H.R. 3014 addresses gaps in our understanding
of disparities by strengthening and coordinating data
collection. It is, frankly, embarrassing that the United
States, with all of our cutting edge science and bio-medical
research cannot extend access to quality healthcare services to
all of its citizens. Passing the Health Equity and
Accountability Act and implementing the provisions within the
bill would bring us much closer to where this country needs to
be in healthcare services.
As we proceed with this hearing, I would like to briefly
note that the Committee is aware of confusion over a drafting
error in the language regarding services for immigrants.
Chairmen Pallone and Dingell are well aware of this and are
prepared to address it as the bill moves forward. And in the
meantime, though, I will encourage all of our members and
witnesses to stay on message with the underlying bill, which
seeks to reduce health disparities like maternal mortality and
access to cancer screenings.
Ms. Capps. With that, I conclude my opening statement and
yield to Mr. Deal, the ranking chair.
Mr. Deal. Thank you, Madam Chairman. In the essence of
time, since we have three panels and the first is our
distinguished colleagues, I will submit my statement for the
record and look forward to the testimony of the three panels. I
yield back.
[Mr. Deal did not submit a prepared statement for the
record.]
Ms. Capps. And now I will turn to the author of the bill,
Ms. Solis, from California.
OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Solis. Thank you, Madam Chair. And I want to personally
thank Chairman Pallone for calling this historic hearing today.
It has been more than 8 years since we have had a discussion on
healthcare disparities in this committee, so I think that this
is a wonderful opportunity for us to hear from our witnesses
and to hear firsthand what the challenges and solutions are
that are being offered in H.R. 3014.
I want to note that the legislation that was crafted was
the work of the Black Caucus, the Hispanic Caucus and the
Asian-American Caucus, as well as many other members of the
healthcare community. I think that this is one of our best
efforts to try to collaborate on bringing together our best
ideas and best practices across the country. Well over 100
Members of Congress are on record in support of this piece of
legislation, and I am very pleased to have the Honorable Mr.
Clyburn here this morning. He will speak on this very important
bill, and I want to thank him personally for his leadership in
helping us to bridge the gap in healthcare disparities among
communities of color. I also want to note that I am very proud
to have, as our panelists, a representative from the National
Council of La Raza and also the APIA Health Forum. They will
shed light on some of the disparities that exist in communities
of color.
As you know, I represent a district in East Los Angeles in
Southern California, where we see these kinds of issues
continuing to grow. And as our economy is not on an upswing, we
see that there are more and more of our youngsters that don't
have good healthcare and good healthcare outcomes. Many of them
are also affected by the fact that they have language barriers.
Many communities do not have a command of the English language,
so providing multi-cultural services to all these under-
represented communities is of utmost importance.
I would like to say also that about a third of the
population in my district is under the age of 6 and has no form
of healthcare insurance. Clearly this is a crisis that we face
in our communities. Language barriers, cultural barriers, and
geographic barriers in rural America impact underserved
communities. Poor whites, Latinos, and other minorities are
disproportionately impacted by asthma, diabetes, HIV, and AIDS.
In addition, 25 percent of Latino children are obese, compared
to 16 percent of African American children and 14 percent of
white children.
Legal barriers also present a great challenge to our
community, especially when we are talking about legal,
permanent resident children. Over the past decade, legal
immigrant non-citizens have faced increasing restrictions on
care to federally funded healthcare programs, such as the 5
year waiting period for programs as Medicaid and SCHIP. H.R.
3014 is necessary to reduce the health inequities that Latinos
and other communities of color and poor whites face.
Even though minority healthcare providers work in
underserved communities, only 4 percent of doctors, 6 percent
of dentists, 4 percent of registered nurses in California are
Latino. Clearly, access is a great systemic problem that we are
seeing with the lack of this representation.
This legislation will increase access to services for the
15 million uninsured people of color, increase the
representation of healthcare professionals in the various
underserved communities, and will provide States with the
option to cover legal, permanent resident women and their
children. It also strengthens our educational institutions like
historically black colleges and Hispanic-serving institutions
to help provide incentives for more of those individuals
seeking careers in the healthcare arena.
This legislation strengthens and coordinates data
collection. How are we able to define the problem if we can't
collect the data? By investing in prevention efforts and in our
healthcare system, I believe that H.R. 3014 will reduce costly
emergency room visits and expensive medical errors. Therefore,
I look forward, today, to hearing the testimony from our
witnesses and thank the members for being here. I would also
like to thank our first panelists, and those that have been
working behind the scenes for many, many years on this
particular bill. Thank you, Madam Chair.
Ms. Capps. Thank you. I now recognize Representative
Blackburn for 3 minutes for an opening statement.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Ms. Blackburn. Thank you, Madam Chairman. I do want to
welcome all of our witnesses that are with us today and I think
that we all agree that preserving and improving access to
quality healthcare is a critical issue and one that does need
our attention. However, this hearing coincides with a critical
issue being addressed on the House floor today, and that is the
Medicare physician payment cuts. While I appreciate the focus
of the hearing, I believe this committee could have used this
time more constructively to address critical and time sensitive
issues such as reform of the Medicare Physician Payment
Formula. Instead, the other side of the aisle dropped a 277-
page bill on Friday, 3 days ago, when there have been no
hearings or mark-ups in this Committee to address Medicare
physician payment.
In fact, this subcommittee, this very subcommittee, has not
held a single Medicare related hearing all year long. I have
met with doctors from all over Tennessee regarding their
concerns about the impending 10 percent payment cut for
physicians under Medicare. This is scheduled to go into effect
July 1, 2008. That is 1 week away and this committee has not
taken one little teeny dab of action to address this and I,
Madam Chairman, think that that is a representation of
misplaced priorities on our issues that are before us.
I have repeatedly supported congressional efforts to
provide physicians with Medicare payment relief through
Medicare reform. As healthcare providers in my district have
stated time and time again, many Tennessee physicians have
already stopped taking Medicare patients. With this cut, a
critical number of doctors will cease to serve Medicare
beneficiaries completely if a solution is not implemented to
fix the physician payment reduction. It is imperative that this
committee and Congress act on this crucial issue now. The
alternative could be disastrous for this Nation's seniors. They
deserve better attention from this very committee. I want to
thank the Chairman and I yield the balance of my time.
Ms. Capps. I now recognize Congressman Green from Texas for
3 minutes for an opening statement.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Ms. Chairman. And following my
colleague from Tennessee, our committee worked last year and
passed the CHAMP bill that corrected the Medicare disparity
issue. And coming from an underserved district and the reason
we are here today is the Health Equity and Accountability Act.
If my doctors didn't take Medicare, they wouldn't be in my
district because typically 40 percent of their medical care
is--50 percent is Medicare/Medicaid and that is what this bill
today, that my colleague Ms. Solis has worked on.
I thank the Chair for holding the hearing on the Health
Equity and Accountability Act. Houston has the third largest
Hispanic population in the country and I represent a district
that I grew up in. It is over 65 percent Hispanic. And I know
firsthand the disparity issue. However, that distinction is
accompanied by a higher rate of diseases like diabetes,
cervical cancer, HIV/AIDS, and the heart disease in our
community. In fact, Mexican-Americans are twice as likely as
Anglos to be diagnosed with diabetes. Hispanic males have three
times the rate of HIV/AIDS, and Hispanic women have five times
the HIV/AIDS rate as their Anglo counterparts.
According to National Center on Minority Health, Mexican-
American mothers are far less likely to receive necessary
prenatal care. To be exact, they are twice as likely to start
prenatal care only in the third trimester or not receive the
care at all. Despite the gloomy picture of Hispanic health
these statistics paint, there is one common theme that these
diseases are for the most part preventable. However, lack of
access to care is still a barrier to minority communities and
part of the cause of many health problems for the Hispanic
community.
In 2006 nearly half of the 47 million uninsured in the
United States were minorities. As we all know, at this
committee, access to quality, primary, and preventative care
leads to better quality of life and fewer health problems down
the road. Yet, minorities still experience access-to-care
issues, language barriers, disparities in the quality of care
for them. That is why I am an original co-sponsor of
Representative Solis' bill and I am proud to be one. It is also
shameful that the minority population still don't have access
to proper healthcare they need and deserve and I want to thank
our witnesses for appearing today, particularly our two
colleagues on our first panel, and I yield back to my time.
Ms. Capps. Thank you, I now recognize the Ranking Minority
member of the full committee for his opening statements, Mr.
Barton from Texas.
Mr. Barton. Thank you, Madam Chairwoman, I will submit my
formal statement for the record. I want to commend our two lead
witnesses, the two distinguished Congressmen, for being here. I
cannot support the bill in its current form. I do think there
are issues that need to be addressed and perhaps we can address
them in this Congress, but for a number of reasons there seems
to be duplicity of requirements in this bill. There is a huge
issue in terms of how you pay for it. There are just numerous
issues with the bill in its current form, but I do think it is
an issue that needs to be addressed and I am glad we have the
two Congressmen here to discuss it. And, if possible, I will be
here to participate in the hearing. I think that you all know
that there is a medical bill on the floor. We are about to take
up a physician reimbursement issue and durable medical
equipment and I will be on the floor on that issue, so I will
be coming and going. But, again, I appreciate the hearing and
hopefully we can work something out, but in its current form,
H.R. 3014, I would not be able to support it. With that I yield
back, Madam Chairwoman.
[Mr. Barton did not submit a prepared statement for the
record.]
Ms. Capps. It is now an honor to recognize the Chairman of
the Full Committee, Mr. Dingell of Michigan, for his opening
statement.
OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Dingell. Madam Chairman, thank you and congratulations
to you, Madam Chairman, on your position as Vice Chair. We look
forward to great things from you. Madam Chairman, I want to
thank you for holding this hearing on a critical health issue,
health disparities, and more specifically, on H.R. 3014, the
Health Equity and Accountability Act of 2007. Before I go into
my statement, I want to welcome and recognize our good friend
Mr. Clyburn from South Carolina, the distinguished Majority
Whip. Mr. Clyburn, welcome. And I want to thank and welcome our
friend and colleague Mr. Moran from Kansas. Welcome. Thank you
for your presence and for your participation in our business
today. Thank you.
Madam Chairman, the existence of racial and ethnic health
disparities in every aspect of healthcare is well documented.
According to the National Institutes of Health, African-
Americans, Hispanics, Native Americans, Asian-Pacific
Islanders, who represent some 25 percent of the U.S.
population, continue to face dramatic differences in health
outcomes compared with white Americans, including shorter life
expectancy, higher rates of diabetes, cancer, health disease,
and stroke. The statistics represent loved ones lost
prematurely and unnecessary suffering and a real unfilled
potential for these people and for this Nation. In a country as
great as ours, the idea that ones ethnic or racial background
factors into your chances of living a healthy and productive
life is totally unacceptable.
It is important to note that one of the key tools in
reducing health disparities is having health insurance. While
having insurance doesn't eliminate disparities, studies show
that the disparities are reduced significantly for those who
have insurance. The CHAMP Act, which I introduced last year,
would make significant headway in reducing the number of
uninsured. The CHAMP Act includes provisions targeted
specifically at reducing racial and ethnic disparities. Some of
the provisions from the CHAMP Act are included in H.R. 3014.
While disparities in health insurance coverage are a major
contributor, there is no single factor responsible for health
disparities that exist. The solution is going to have to be
multifaceted.
The subject of today's hearings, H.R. 3014, provides a
comprehensive solution that will take us a long way toward
addressing the problem of health disparities among our people.
H.R. 3014 includes provisions to expand cultural and
linguistically appropriate care, work force diversity, data
collection, accountability, improvement of health services, and
rural health.
I want to commend our good friends Representatives Solis
and Towns for their leadership on this issue. I also want to
thank and recognize members of the Tri-caucus for their efforts
on this legislation and their persistence of bringing the issue
of health disparities to the forefront. Madam Chairman, I look
forward to the comments of my colleagues and the testimony of
our witnesses today about addressing this serious problem.
Again, I welcome our good friend, Mr. Clyburn and Mr. Moran for
their presence here and for their leadership and help to the
Committee. I look forward to their testimony and thank them for
their leadership on this issue, and so many others. Thank you
Ms. Chairman.
Ms. Capps. I, now, recognize our colleague, Ms. Baldwin
from Wisconsin, for 3 minutes for an opening statement.
OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WISCONSIN
Ms. Baldwin. Thank you, Madam Chair. I am proud to be a co-
sponsor of the legislation before us, H.R. 3014, and I am
really delighted that our committee is holding hearings on this
legislation. I want to thank my colleague and friend
Congresswoman Solis for her tremendous leadership on this
issue, and many thanks to you also Majority Whip Clyburn and
Congressman Moran for being with us today. I look forward to
hearing your testimony, along with the testimony of all our
other expert witnesses.
Evidence clearly indicates a persistent disparity in health
status of racially and culturally diverse populations as
compared with the overall health status of the country. We know
that over the next decade, our demographic composition of the
United States will become more racially and ethnically diverse
and will only increase the need for effective prevention
programs tailored to specific community needs. The fact that
racial and ethnic minorities continue to receive a lower
quality of healthcare than non-minorities is unacceptable and,
frankly, un-American. And I believe that all Americans deserve
access to affordable, comprehensive healthcare.
I do want to make a record of my interest, also, in having
this committee and this Congress address the healthcare
disparities faced by another community, the LGBT, lesbian gay
bi-sexual and trans-gender community, as we move forward with
legislation addressing healthcare disparities. For example,
although much has been done to educate the public on how HIV
and AIDS continues to devastate LGBT populations, many
Americans, perhaps some in this room, do not know that gay men
and lesbians are at heightened risk for certain cancers. Many
do not know that LGBT youth are two to three more times likely
than heterosexual youth to attempt suicide, or that LGBT
populations have a combined smoking rate almost double that of
the general population. In fact, also, few healthcare providers
are trained in how best to serve LGBT patients with culturally
competent care. And we know that the community suffers from an
alarming lack of data. For example, no national cancer
registries collect data based on sexual orientation or gender
identity. Just this basic inclusion in registries and large
national surveys could answer many simple questions and even
point towards new research opportunities.
Now, back to the legislation before us, I wholeheartedly
support our committee's effort to quickly and effectively
address cultural and linguistically appropriate care, workforce
diversity, data collection, increased accountability, and
overall improvement of health services for underserved minority
population and it is my hope in doing so that we also keep in
mind significant barriers to good healthcare faced by those who
are in the LGBT community. Again, thank you for holding this
hearing and to our panel of witnesses for their time.
Ms. Capps. Thank you, I now recognize our colleague from
Illinois, Representative Schakowsky, for 3 minutes for an
opening statement.
OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF ILLINOIS
Ms. Schakowsky. Thank you, Madam Chairman, I will keep my
comments short, but I do want to commend Congresswoman Hilda
Solis, the sponsor of H.R. 3014, which you are considering
today and a bill which I am proud to be a co-sponsor of. As the
Chair of the Hispanic caucuses' task force on health and a
member of the Asian Pacific American caucus, Congresswoman
Solis has long fought for eliminating the racial and ethnic
health disparities that persist across this country. I want to
associate myself, also, with Congresswoman Baldwin's remarks
about a long overlooked constituency, as well.
I commend that hard work and as a co-sponsor I am very
pleased to be discussing this absolutely critical bill in our
subcommittee today. In general, our country has seen some
significant improvements in health and well being over the past
several decades, but certainly this progress has not touched
every population. The differences in health outcomes across
racial and ethnic populations such as life expectancy, rate of
diabetes, cancer, heart disease, and stroke that exist within
each and every one of our districts must not be tolerated any
longer. While it is my sincerest wish that the near future hold
a system of healthcare for all in this country, we must take on
the fight of eliminating health disparities today. Otherwise,
we run the risk of permitting these gross inequities to
continue into that system and surely allow this unequal system
to rob the futures of more and more Americans.
This bill will make strides toward a more equitable system
for all by improving data collection, accountability and access
to care and working to increase workforce diversity and
culturally and linguistically appropriate care. I am proud that
in Chicago, Asian Human Services has created a community health
center focused on providing culturally sensitive care to the
Asian American community. More proactive steps like that are
needed and this bill will help us to do that. I am so anxious
to hear from our witnesses today and I thank Congresswoman
Solis again for her tireless leadership on these issues and I
yield back.
Ms. Capps. Thank you. I, now, recognize the co-author of
the bill under consideration today, Mr. Towns from New York,
for 3 minutes for his opening statement.
Mr. Towns. Madam Chair, I would like to waive my opening
statement. I hear the bells are sounding and of course I would
like to.
[The prepared statement of Mr. Towns follows:]
Prepared Statement of Hon. Edolphus Towns
Thank you Chairman Pallone and Ranking Member Deal for
scheduling this hearing regarding H.R. 3014, ``Health Equity
and Accountability Act of 2007''. This bill can be greatly
instrumental in helping our Nation eliminate the health and
health care access disparity divide.
I especially would like to thank Representatives Hilda
Solis (CA), Donna Christensen (VI) and Doris Matsui (CA), and
others for their exhausting and enlightened leadership on this
bill that has a total of 110 co-sponsors of which I am proud to
be a co-sponsor. I appreciate the collective input and wisdom
of the Congressional Black Caucus, the Hispanic Caucus, and the
Asian Pacific American Caucus. I think it is also befitting to
establish the Robert T. Matsui Center for Cultural and
Linguistic Competence in Health Care after the late
representative. I welcome our witnesses, especially my esteemed
congressional colleagues, Representatives James Clyburn (SC)
and Jerry Moran (KS).
I also respectfully ask for unanimous consent to admit
certain documents into the record.
With that, I yield back and thank you, Mr. Chairman.
----------
Ms. Capps. Thank you. Now we turn to panel one and we will
ask each of our colleagues to present 5 minutes of their oral
testimony. There will be no questions from the members for the
first panel. Mr. Clyburn, you may begin.
STATEMENT OF HON. JAMES E. CLYBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF SOUTH CAROLINA
Mr. Clyburn. Thank you very much, Madam Chair. I too hear
those bells and I apologize, but let me begin by thanking you,
Madam Chair, the other members of the Committee, especially
Chairman Pallone and Ranking Member Nathan Deal for allowing me
to testify in support of H.R. 3014, the Health Equity and
Accountability Act of 2007. I also want to acknowledge the
tireless work of our Congressional Tri-caucus, in particular
the health chairs, representatives Donna Christensen, Hilda
Solis and Madeleine Bordallo.
Now, Madam Vice Chair, we know that prevention and control
of the diseases and the protection and promotion of people's
health are the primary mandates of public health. The
fulfillment of this goal does not solely rely on the
government, but needs support of the private sector,
communities, families and individuals.
We also know that socioeconomic conditions are known to be
major determinates of health at all stages of life from
pregnancy through childhood and on into adulthood. These social
determinants of health and their association with adult
morbidity and mortality, and adult health related behaviors are
well documented. Yet we know that episodic intervening in the
health system is insufficient to influence health early in the
life course. Community-level approaches to impact key
determinants of health are also important.
Now, Madam Vice Chair, in 2005 a United Nations Development
Program report entitled, Inequality in the United States
Healthcare System stated the following: ``Although the United
States has been rated highly in the United Nations Human
Development Index, the shining health indicators of the general
population do not reflect the great disparity in the health of
certain subpopulations. Absolute health indicators often make
the suffering of the vulnerable, especially those living in the
wealthiest nation, invisible to the world.'' The report
continued stating that the United States private-public
healthcare system should not be used as a model for other
countries as it exacerbates the inequality in access to care
and health status between the haves and the have-nots.
Now, Madam Chair, I have other things that have been
prepared for me to say, but in the interest of time I am not
going to. I am going to ask that you allow me to enter my full
statement into the record, but I thought it was important for
me to get that statement in.
Now, I want to close my comments, Madam Vice Chair, by
saying I am no healthcare expert, but I have seen enough of my
friends, family, and most recently a beloved employee die from
diseases that this bill seeks to address. And I cannot think of
a better way--my wife suffered from a heart attack and had a
five vessel bypass surgery and on the day that I stood with
her, as they were about to discharge her from the hospital, the
doctor said something to the effect, I think we caught whatever
it was in time. And then asked her, how does she feel. She said
something is wrong. Now, this was the fourth day in the
hospital, but she came, really, from a part of town that people
just didn't think she would be having a heart attack. Yet, they
finally decide to put the dye in, and when they did they found
three 100 percent blockages and two 50s.
Now, I point this out to say to you, Madam Chair, that I
came here today to testify on behalf of people who do not have
good healthcare. I would not be celebrating with her our 47th
anniversary today were it not for the fact that they took a
second look. Not because of what her disease was, but because
of who she was, and that is why we are here today. Thank you,
Madam Chair, and I yield back the rest of my time.
[The prepared statement of Mr. Clyburn follows:]
Statement of Hon. James E. Clyburn
Good morning,
I want to offer my sincere thanks to Chairman Pallone and
Ranking member Nathan Deal for allowing me to testify in strong
support of H.R. 3014 the Health Equity And Accountability Act
of 2007. I also want to acknowledge the tireless work of our
Congressional Tri-caucus, in particular, the Health Chairs
Representatives Donna Christensen, Hilda Solis, and Madeleine
Bordallo.
Mr. Chairman, we know that prevention and control of
diseases, protection, and promotion of the health of the people
are the primary mandate of public health. The fulfillment of
this goal does not solely rely on the government, but needs
support of the private sector, communities, families, and
individuals.
We also know that socioeconomic conditions are known to be
major determinants of health at all stages of the life course
from pregnancy, childhood, and adulthood. These social
determinants of health and their association with adult
morbidity and mortality, and adult health related behaviors are
well documented. Yet we know that episodic intervening in the
health system is insufficient to influence health early in the
life course; community-level approaches to impact key
determinants of health are also critical.
Mr. Chairman, in 2005, a United Nation Development Program
(UNDP) report entitled, Inequality in the United States
Healthcare System stated the following: ``Although the United
States (US) has been rated highly in the United Nations Human
Development Index, the shining health indicators of the general
population do not reflect the great disparity in the health of
certain subpopulations. Absolute health indicators often make
the suffering of the vulnerable, especially those living in the
wealthiest nation, invisible to the world.'' The report
continued stating that, the US private-public healthcare system
should not be used as a model for other countries as it
exacerbates the inequality in access to care and health status
between the haves and the have-nots.''
Consider these statistics:
Infant mortality rates are higher among African
Americans and American Indian/Alaska Natives than among other
racial/ethnic groups, even when comparing women of similar
socioeconomic conditions.
On average, Latinos, African Americans, American
Indians, and whites have higher mortality rates than Asian/
Pacific Islanders at each stage of the lifespan.
These differences could be attributed to delaying
care: 32% of Latinas and 32% of African American women report
delaying or foregoing care in the past year, as did 15% of
white women. Women report several reasons for delaying care,
including cost, lack of insurance, and competing family or work
responsibilities.
But these statistics are not surprising or new information,
for in 1985 former Health and Human Services Secretary Margaret
Heckler published a report from her Task Force on Black and
Minority Health which stated that because of these ``stubborn
disparities'' America was on course to creating a ``permanent
health and healthcare underclass.''
Those words came true and became the core argument
presented in the landmark Institute of Medicine report
published in 2002 on disparities entitled Unequal Treatment:
Confronting Racial and Ethnic Health Disparities. This report
laid bare the fact that there is healthcare underclass and it
is US private-public patchwork healthcare system is to blame.
Although the US healthcare system emphasizes competition, a
trademark of privatization, competition occurs at the wrong
level. The relevant arena to have competition is in diagnosing
and treating particular diseases or conditions, thus creating
an atmosphere that rewards value and quality. However, in the
US, competition exists among provider networks, whether they
consist of hospitals or doctors or both, to assemble bargaining
power so that they can strike a better deal for themselves;
healthcare is treated as a commodity. However, this kind of
cost-shifting or bargaining-power competition does not reward
quality or create health care value. It actually does the
opposite through adding massive administrative costs,
inequities, and complexity into the system.
This is why I am so happy to see this Congress go on record
and commit themselves to the elimination of racial and ethnic
disparities in health care access, health care quality, health
outcomes and the health care workforce because all Americans
deserve equal treatment in health care. A proper investment in
health care will improve both the health and economic well-
being of our country. The legislation before us today seeks to
address racial and ethnic health disparities by doing the
following:
Setting the elimination of racial and ethnic
health disparities as a goal. The elimination of racial and
ethnic health disparities can and should be a goal for all
Americans. The health of all communities is enhanced when we
work to close the health care divide.
Expanding the health care safety net. The lack of
health insurance and access to health services results in
significant declines in health status within racial and ethnic
minority communities. The availability, quality, and
affordability of health coverage options that provide
meaningful access to health services must be expanded in
cooperation with health care providers and employers in order
to successfully address racial and ethnic health disparities.
Diversifying the health care workforce. Develop a
diverse public health workforce that reflects and understands
the backgrounds, experiences, and perspectives of the
population it serves. Efforts should be made to recruit and
train health care professionals from underrepresented groups.
In addition, the training of health professionals should be
expanded in order to produce a culturally and linguistically
proficient health care workforce.
Ensuring Health Care Access in Compliance with
civil rights laws. Title VI of the 1964 Civil Rights Act and
its subsequent amendments provide crucial rights to individuals
with limited English proficiency (LEP) to access federally
conducted and supported programs and activities. LEP persons
should not be inhibited from accessing vital health care
services paid for by their and their families' tax dollars.
Promoting the Collection and Dissemination of
Data. In order to fully understand the scope of health care
disparities, it is necessary to have data on individuals'
health care access and utilization that includes race,
ethnicity, primary language, immigration status and socio-
economic status. Data is necessary in order to measure the
existence, effects, and causes of health care disparities.
Ideally, good data collection can lead to a model of
appropriate intervention.
Combating diseases that disproportionately affect
racial and ethnic minorities. Existing research has illustrated
that diseases such as diabetes, obesity, heart disease, asthma,
and HIV/AIDS disproportionately impact racial and ethnic
minorities. Federal initiatives should focus on preventing and
treating these diseases, educating all communities about their
impact, and identifying the behavioral, emotional, and
environmental factors that contribute to these diseases.
Enhancing medical research that benefits all
communities. It is important that federal medical research be
conducted by, and on behalf of, racial and ethnic minorities.
There is a need to recruit medical researchers who are
culturally and linguistically proficient and train those who
are not. In addition, additional research must be done to
analyze the impact, cause, and effect of disease on racial and
ethnic minorities.
Emphasizing a holistic prevention and behavioral
health approaches. Estimates suggest that as much as fifty
percent of health care costs are caused by behaviorally related
illnesses, including heart disease, high blood pressure,
obesity, and substance abuse. Cultural and social factors can
contribute to the behavioral patterns underlying these
illnesses. Behavioral interventions have the potential to
prevent such illnesses and save billions of dollars in health
care costs.
Recognizing the complexity of racial and ethnic
communities. The diverse communities within our nation present
unique health concerns. Acknowledgement must be given to the
impact of a person's race, ethnicity, national origin,
generation of immigration, educational and socio-economic
level, geographic location, cultural beliefs, immigration
status and linguistic preference on health status.
Mr. Chairman, last year during the floor debate on
reauthorizing the Child Health Insurance Program, I invoked an
old judicial axiom that says ``Justice delayed is justice
denied.'' My colleagues the same is true for health care.
Whether it is the story of thirteen-year-old Devante Johnson
from Houston, Texas who had advanced kidney cancer and spent 4
desperate months uninsured while his mother tried to renew his
SCHIP coverage only to die in the process.
Or 43-year-old Edith Isabel Rodriguez who laid in pain for
45 minutes on the emergency room lobby floor of Martin Luther
King Jr.-Harbor Hospital and later died of a perforated bowel,
as janitors sweep around her and hospital staff ignored her.
To the Members of the Committee, I am no healthcare expert
but I have seen enough of my friends, family, and most recently
a beloved employee of mine (Mr. Ike Williams) die from the
diseases that this bill seeks to address and I cannot think of
a better way to acknowledge these deaths and bring justice to
those who have died prematurely because of disparities in
healthcare then to pass this bill.
We need this bill, the American public wants this bill, and
it should be noted that the entire leadership of the House will
see to it that this bill becomes law.
Thank you Mr. Chairman for allowing me to offer my thoughts
on this important piece of legislation. I apologize for having
to leave after this testimony but if you have any questions
please follow up with my policy director Aranthan S. Jones, II
or ``AJ'' in my office.
As you many of know, AJ is the coauthor of the bill before
us and is known on Capitol Hill as the preeminent expert on
health disparity elimination policy. It is my sincere hope that
as you move this legislation and legislation akin to its
substance, that you use him as a resource. Thank you Mr.
Chairman.
----------
Ms. Capps. Thank you Mr. Clyburn for your oral testimony
and your written testimony. Without objection, we will allow
Mr. Clyburn's full statement to be entered into the record.
Thank you very much, and I know that we have just 10 minutes
left on our vote, but we will now turn to the Honorable Jerry
Moran from Kansas for his testimony.
STATEMENT OF HON. JERRY MORAN
Mr. Moran. Madam Chairperson, thank you very much for
allowing me the opportunity to join you today, and it is
particularly an honor to be here with the distinguished
gentleman from South Carolina, and I wish him a happy
anniversary on this special occasion.
Mr. Clyburn. Thank you.
Mr. Moran. I am--my guess is focused on the portion of the
title of your hearing that says, ``and other health
disparities.'' Although the distinguished woman from
California, Ms. Solis and the distinguished doctor from the
delegate from the Virgin Islands, Dr. Christensen and I
participated in a hearing earlier this month with the Ways and
Means Committee, and I am certainly interested in learning and
hearing more about disparities in a population that needs
attention.
But I come today to talk about disparities that exist in
rural America and in many instances I believe they overlap with
the things that I have heard from Ms. Solis and others. I
represent a congressional district that is nearly 60,000 square
miles. There are 69 counties. My largest community, largest
city is 45,000 people. It would be considered by any standard a
rural district and healthcare is one of those factors that is
so important in the future of those communities. It is about
saving lives today, but it is about whether there is an
opportunity for children and grandchildren to raise their
families in the places that parents call home.
I have concluded that healthcare, its access and its
affordability is, perhaps the number one issue that we face
domestically in this country. If you take a look at rural
America, you would see a population that is aging. The
demographics are much older than the rest of the country and it
is challenging for people to access healthcare because of age
and disability but also because in rural America there is
virtually no public transportation system. And so, because of
the distances and yet because of the age, those two factors
come together to make access extremely difficult. Rural elderly
are more likely to have chronic diseases and yet 10 to 20
percent, statistics show, less likely to have access to any
pre-screenings, preventative care and checkups. And so, once
again, the paradox is that we have an older population with
less ability to access healthcare and therefore less ability to
prevent the deterioration of their health.
We are also poor. Rural America is poorer than urban
America with an average per capita income of about $7,000 less
compared to urban areas. Nearly 24 percent of children who live
in rural America grow up in poverty. I have, for much of the
time I have been in Congress, in fact the entire time I have
been in Congress, been an acting member of the Rural Healthcare
Coalition and for much of the time have co-chaired the Rural
Healthcare Coalition, and one of the appealing and satisfying
aspects of that is that so much of what we pursue and so many
members of that coalition are urban members of Congress. We
share in rural America many aspects of the delivery of
healthcare that core centers of cities, urban core centers
share, and so it is an opportunity for us to come together to
battle a problem that is common among two different areas of
the country.
Uninsurance is certainly an issue in this country, but it
is especially an issue in rural America. In my congressional
district, particularly in the southwest part of that district,
which is the most geographically isolated and the most
ethnically diverse, 16.8 percent of my citizens lack healthcare
coverage, and yet in the more urban, northeast corner of
Kansas, that number is 7.5. So, even within a rural State like
Kansas there are significant disparities between rural and
urban areas.
It is difficult for us to keep our healthcare delivery
system in place. Hospitals are struggling to keep their doors
open. The critical access healthcare program has been something
that has allowed that to be an opportunity, but we have a
tremendous physician shortage, nursing shortage, dentist
shortage. Of the healthcare professional shortage areas in the
country, 2,157 of them are in rural areas. Nine-hundred and ten
of them are in urban areas. Twenty-five percent of Americans
live in rural America and yet 10 percent of physicians practice
in rural America. So access to hospitals and doctors is a
significant challenge.
Most recently I am pleased that the legislation we are
considering today deals with some aspects of pharmacy. I
represent seven counties in Kansas that have no pharmacist in
the county. 32 only have one pharmacist in the county, and what
we have done in regard to the prescription drug benefit as well
as other policy decisions we have made in many instances has
exacerbated the problem.
Medicare and Medicaid have a significant component in the
payment for healthcare. Many of my hospitals and physicians--
60, 70, 80, and sometimes 90 percent of the patients that are
admitted to a hospital in Kansas or seen by a physician, their
bills are paid by Medicare.
And finally I would say that emergency medical services is
a significant issue for us in rural America. The time to
respond is a significant challenge, but also Madam Chairperson,
in most instances, our EMS professionals are volunteers and as
the population increases in age, the number of younger
volunteers becomes a significant challenge. So, I recognize
that the time has expired and I am delighted to be with you. I
am happy to highlight these disparities and work with my
colleagues, from across the country, as we try to make certain,
as Mr. Clyburn said, that there are no differences between the
haves and the have-nots. Thank you Madam Chairperson.
[The prepared statement of Mr. Moran follows:]
Statement of Hon. Jerry Moran
Thank you for the opportunity to testify about disparities
in rural healthcare. I represent a congressional district that
is nearly 60,000 square miles and has 69 counties. The largest
community has a population of about 45,000 people and so I have
what most people would consider a very rural district. There
are a number of factors regarding rural districts across the
country that come together to create significant disparities in
the availability and affordability of healthcare.
If you took a snapshot of rural America you'd see a
population that is aging faster than in other places in the
country. Because many rural residents are elderly, they use
more healthcare services. It can be challenging for these rural
residents and their families to get to the doctor. Residents in
rural Kansas have virtually no access to public transportation
and must drive long distances to access health care and because
of that, preventive care can be very limited. The rural elderly
in Kansas are more likely to have chronic diseases and yet are
10 0920% less likely to receive the recommended pre-screenings,
preventive screenings, and checkups.
Compounding the problem of access, rural residents also
tend to be poorer and make less than their urban counterparts,
a per capita average income $7,000 less compared to urban
areas. Nearly 24% of children who live in rural America are in
poverty.
Higher rates of uninsurance are also found in rural
communities. For example, in the southwest part of my
congressional district, which is the most ethnically diverse
and geographically isolated, 16.8% of the citizens lack
healthcare coverage, compared with 7.5% of their fellow Kansans
in the northeast, urban part of the state.
It is also extremely difficult to keep the proper
healthcare infrastructure in place in rural America. It is
extremely challenging to recruit and retain healthcare
personnel to practice in rural areas when they can make more
money serving patients who are younger and wealthier in more
urban environments. There are 2,157 Health Professional
Shortage Areas (HPSAs) 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 them are rural
counties.
Having access to local hospitals, emergency services, and
pharmacies is something that rural residents do not take for
granted. It is difficult to keep the doors open for many rural
hospitals. In fact, 470 have ceased operations in the last 25
years because there are fewer patients in rural areas and
Medicare payments to rural hospitals and physicians are
dramatically less than those paid to their urban counterparts
for the same services. Medicare use is extremely high in rural
districts. In fact, at Smith County Hospital, which is along
the Kansas-Nebraska border, 8 out of 10 patients admitted to
the hospital are Medicare beneficiaries.
In some of my rural counties, the only access to healthcare
services is Emergency Medical Services. It should be noted that
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. Statistics
show that the average response time in rural areas is 8 minutes
more than the typical response time in an urban area. Finally,
in most rural areas, the emergency service providers are
volunteers. As the rural population continues to age, the lack
of young people to fill these critical volunteer positions will
continue to compromise the rural healthcare system.
Finally, 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.
Community pharmacies are an important component in providing
healthcare in rural communities. Seven Kansas communities have
no pharmacy and 32 counties only have one pharmacist. Adequate
and timely reimbursement for our pharmacies who are serving the
Medicaid population and some of our most vulnerable citizens is
a necessity in order to ensure access for these populations.
So, as we look at ways to try and eliminate disparities in
our health care system, I welcome the opportunity to shed light
on the realities that rural communities and their residents
across the country are facing. I thank the chairman and ranking
member for inviting me to testify, and I would be happy to
respond to any questions.
----------
Ms. Capps. Thank you Mr. Moran. We now have one vote on the
floor so the subcommittee will recess until 15 minutes after
the vote. And as we do, we want to wish Mr. and Mrs. Clyburn a
very happy wedding anniversary.
Mr. Clyburn. Thank you.
[Recess.]
Ms. Solis. I would like to reconvene the committee hearing.
We will ask our second panel to please join us and we will hear
5-minute opening statements from our panel's witnesses. And
each part of their statements will be made part of the record
and each witness may, in discretion of the Committee, submit
additional brief or pertinent statements in writing for
inclusion in the record. I would like to thank our two
panelists today. We have Dr. John Ruffin, Director of the
National Center for Minority Health and Health Disparities with
the National Institute of Health and we also have Garth Graham,
Dr. Graham, who is Deputy Assistant Secretary for Minority
Health Office of Public Health and Science, Office of the
Assistant Secretary of Health Department of Health and Human
Services. Both will have 5 minutes to speak to us and we will
begin with Dr. Ruffin. Thank you.
STATEMENT OF JOHN RUFFIN, PH.D., DIRECTOR, NATIONAL CENTER ON
MINORITY HEALTH AND HEALTH DISPARITIES, NATIONAL INSTITUTES OF
HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Ruffin. Thank you, Madam Chair, good morning.
I am pleased to have this opportunity to brief you on the
NIH and, more specifically, the National Center on Minority
Health and Health Disparities efforts in furthering biomedical
research to eliminate health disparities. By the year 2030, by
all indications, racial ethnic minorities will make up almost
50 percent of the U.S. population. If the health disparities
trend continues along the current path without aggressive and
transformational interventions we will be faced with a
resource-strained health care system with the majority of the
population in poor health and a workforce that is not
representative of the patient population. Madam Chair, to
preempt this prediction of health disparities, keep pace with
the changing demographics and evolving health disparities
environment, a paradigm shift is needed. New approaches and
research capacity building and outreach will be critical to
address the complex factors that contribute to health
disparities such as biology, culture, socioeconomics
discrimination, politics, and environment.
At the NIH, our goal is to advance research to better
understand these interacting factors and build a multifaceted
enterprise defined in solutions. The National Center on
Minority Health and Health Disparities was established by
Public Law 106 09525. Its purpose is to improve the health
populations experiencing disparities in health, and to
eliminate health disparities. By law, the NCMHD has two key
responsibilities, one to conduct and support research by
funding and administering its own programs, and two, to be the
focal point for minority health and health disparities research
at the National Institutes of Health.
Our goals focus principally on four areas: one, research,
which is to enhance our understanding of the multi-factorial
causes of health disparities. The center of excellence program
supports the NCMHD premiere research being conducted in 31
States, the District of Columbia, Puerto Rico, and the U.S.
Virgin Islands. A total of 88 institutions have received
funding under this program, but about 50 are still being
funded.
Another goal is training. Training is essential because we
need a strong diverse and culturally competent workforce to do
the research and to serve the rapidly increasing patient
population. The loan repayment program has funded more than
1,400 health professionals to engage in health disparities
research. The largest representation is among Caucasian, 37
percent, followed by African Americans, 34 percent, and
Hispanics, 14 percent, and 4 or less American Indians
comprising of only 2 percent, and Asian and Pacific Islanders
making up 9 percent. Our training and research activities
extend beyond our domestic borders. Health disparities
transcend borders, and we are developing future scientists to
tackle health disparities on the domestic and the global front.
Our own minority health and health disparities international
research training program funds 24 domestic institutions to
train students and faculty in research related to minority
health and health disparities at almost 50 international sites.
These countries include India and Ghana and Jamaica and Chile,
France, Poland, and New Zealand, and there are many more.
Capacity building is another goal for us. In order to do
cutting edge research, our institutions, community based
organizations and researchers need resources to build and
maintain an updated infrastructure. Our programs that support
capacity building include the endowment program, which has
funded approximately 16 institutions. Funding has helped some
of the institutions to develop involved chairs, programs in
diseases like HIV/AIDS, cardiovascular disease or build, as you
heard Congressman Morgan say earlier, build pharmacy schools
and public health programs. Similarly, the research
infrastructure in minority institution program is assisting
about 21 institutions in 16 States and Puerto Rico to develop
science and research programs to begin molding young research
investigators.
Finally, we emphasize outreach because we must translate
our research findings and share the lessons learned. We also
have to disseminate the information into the community and
provide the public and health professionals with the tools
needed to improve the community's quality of health and
ultimately eliminate health disparities. The community-based
participatory research program is our principle vehicle for
community outreach. The uniqueness of this program is that it
involves the community and the entire research process from
needs assessment, research intervention to information
dissemination. We supported 25 awards during the planning phase
and now are preparing to fund about 40 for the research phase.
These are the types of responsibilities that the originating
Law gave the NCMHD and the programs it mandated. We have
implemented those mandates and now are starting to develop
other initiatives to strengthen our efforts. In addition, we
collaborate with other NIH institutes and centers and with
other federal agencies on several projects.
Ms. Solis. Dr. Ruffin, could you summarize? Your time is
up.
Mr. Ruffin. Yes. We are beginning to establish a good
foundation and partnership is at the cornerstone of our effort,
but considering the various factors such as cultural, biology,
and environment that we believe contribute to health
disparities, the infrastructure that we have established has to
be strengthened. It has to be expanded and sustained if we are
to truly eliminate health disparities.
Ms. Solis. Thanks.
Mr. Ruffin. Again, thank you.
[The prepared statement of Mr. Ruffin follows:]
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Ms. Solis. Thank you very much. Our next witness is Dr.
Garth Graham. Welcome. Thank you for being here and you have 5
minutes.
Dr. Graham. Thank you.
STATEMENT OF GARTH GRAHAM, M.D., M.P.H., DEPUTY ASSISTANT
SECRETARY FOR MINORITY HEALTH, OFFICE OF PUBLIC HEALTH AND
SCIENCE OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Graham. Good morning Madam Chairman and other
distinguished members of the subcommittee. I want to take this
opportunity to thank you for inviting me to testify today and
also to thank you for your ongoing efforts to reduce and
hopefully eliminate health disparities. It is always a pleasure
to talk about issues that are very near and dear to all of us,
issues that serve and affect the lives and well being of so
many people in our country.
The Office of Minority Health resides within the Office of
Public Health and Science in the Office of the Secretary of the
U.S. Department of Health and Human Services. Its creation in
1986 by then HHS secretary Margaret Heckler was one of the most
significant outcomes of the 1985 Secretary's Task Force Report
on Black and Minority Health. OMH was subsequently established
in statute by the Disadvantage Minority Health Improvement Act
of 1990 and reauthorized under the Health Professions Education
Partnership Act of 1998. Yet in the past 20 years we continue
to understand that disparities not only continue to exist, but
remain persistent.
The most recent healthcare disparities report has shown
that progress is being made, but many of the biggest gaps
remain. Over 60 percent of disparities in quality of care have
stayed the same or worsened for blacks, Asians and poor
populations. Nearly 60 percent of disparities have stayed the
same or worsened for Hispanics and for blacks, Asian Hispanics
and poor populations. Disparities in about half the core
measures of access to care are lessening.
Building on strategies, such as those recommended in the
2002 IOM report and others, the OMH has been working to
increase awareness around health disparities, improve cultural
competence in healthcare, work on strategies to improve data
collection, and promote the consistency of care through the use
of evidence-based guidelines. In addition, we look to develop
new strategies in looking at health information technology as a
tool to reduce disparities as well as dealing with emergency
preparedness in minority communities.
A recent example, on June 12 of this year here in
Washington, we launched a National Health IT collaborative for
the underserved. This is a brand new effort which aims to
ensure that underserved populations are included as health
information technologies are developed and deployed. We work
with three organizations in organizing this collaborative: The
Summit Health Institute for Research and Education; The Health
Information and Management Systems Society; and Apptis Inc., of
Chantilly, Virginia. They will be joined by additional Federal
agencies, and private sector and community-based stakeholders.
It is an ambitious and energetic group that expects to recruit
leaders and subject matter experts in technology, education,
outreach, advocacy, public policy, workforce development
training, and funding.
In the area of emergency preparedness we supported Drexel
University in developing a National consensus statement that
provides broad guidance, identifies priorities for integrating
culturally diverse communities into public health preparedness
planning and implementation. We worked to create the Nation's
first online clearing house and information exchange site,
designed to help eliminate disparities for culturally diverse
communities across all stages of an emergency.
There are a lot more efforts that I could discuss. We have
been working in particular in dealing with the intractable
problem of the infant mortality disparities in African American
communities compared to the general population. I could talk
more about our support for a task force seeking to promote
broader immunization coverage for Hepatitis B vaccinations
among Asian Americans, Native Hawaiians, and other Pacific
Islander populations. I could also talk about our work with the
Baylor College of Medicine and Intercultural Cancer Council to
publish guidelines and best practices for researchers in
organizing culturally competent clinical trials.
Every day brings new opportunities and new beginnings. We
have set a course that focuses on ensuring that our work is
transparent, our contributions are targeted, and we achieve a
return on our investment. We can't do this and work alone. We
recognize that we have numerous partners in the field from the
National Medical Association, the National Hispanic Medical
Association, the Summit Health Institute of Research and
Education, National Council of La Raza, and many others in the
Asian American and Pacific Islander Health Forum and many
others who have joined us in our efforts here today. Efforts
around reducing and ultimately eliminating health disparities
require strong leadership and OMH is up for the task. Working
together we can make an even bigger difference in the lives of
people. Thank you for the opportunity to testify, and I will be
happy to answer any questions you may have.
[The prepared statement of Dr. Graham follows:]
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Mr. Pallone. Thank you, Dr. Graham. Thank you both. We are
now going to have questions from the panel and I will start
with myself, and I do apologize. I think maybe Congresswoman
Solis or Capps mentioned that we have the Medicare Physician
Reimbursement bill on the floor, so there is a lot going on at
the same time. But I did have your written testimony so I
wanted to start. I ask a question of Dr. Graham. You mention in
your testimony that the Office for Minority Health leads a
working group as part of the HHS Data Council on Racial and
Ethnic Data. Can you talk about what opportunities this
particular data collection system has helped you to identify?
In addition, have outside groups assessed the same data in ways
to help advance other solutions and proposals to address health
disparities?
Dr. Graham. Sure. One of the main challenges that we face
is a lack of data for specific subpopulations of the American
population, Native American populations, Native Hawaiian or
Pacific Islander populations, sub segments of the Hispanic
populations and others. We have been working on a series of
efforts to try and figure a cost effective mechanism to be able
to not only collect but also be able to report on the data in
those very subpopulations. So one of the things we have done is
we have created an online data portal on all of the various
data that HHS and other private organizations and other
partners, I should say, have on these very subpopulations so
that they can be available to researchers and other policy
makers across the board.
We have also been looking at unique methodologies in terms
of increasing data collection on those subpopulations that I
was just describing. I have to tell you that it is a large task
and as we look through these strategies and as we try to figure
out ways in which to do this, we do find that there are
interesting ways in which we can do this and we have been
working with RAND Corporation to hopefully identify some
further opportunities.
Mr. Pallone. All right, well thank you. I appreciate you
mentioning, particularly, Native Americans because I know that
Ms. Solis' bill came from the Tri-caucus but the Native
American caucus, which I actually vice chair, was very
supportive of the legislation as well and they, of course, have
huge disparities, as well. In your testimony, though, you
provide impressive numbers about the number of individuals that
have been served by programs such as interpretation and
translation services, health education, outreach, referral
monitoring services. Has your office conducted any research to
determine the impact of these types of programs on the
populations they serve? For example, for 1,052 people served by
the mentoring program, I would be curious to know if their
health outcomes are better than they would have otherwise been.
Dr. Graham. Sure. We continue to provide--I am sorry, we
continue to assess our efforts and evaluate our efforts on an
ongoing basis and we have a uniform data management system that
we put in place and not only capture what our grants do, but
also to be able to make sure that we tie and link those to
health outcomes. Now, one of the things, Chairman, that we do
know in terms of looking at some of our programs that increase
training and increase opportunities for younger individuals,
one of the programs that you just mentioned to enter health
professions is beyond just the data that OMH has. We do know
from Sullivan Report, the Institute of Medicine Report and many
other reports that increasing diversity in the work force needs
to be a priority in terms of the elimination of health
disparities. Our efforts go along those lines and hopefully
serve to strengthen and create opportunities for younger
individuals to enter the pipeline and enter pipeline programs,
and that is where those efforts are targeted.
Mr. Pallone. OK. Let me ask Dr. Ruffin, I know that you
changed your plans to be here today and you have to catch
another plane so thank you for making those arrangements so you
could be here. There are some who feel that there should be
minimal to no Federal involvement in trying to close health
disparities gaps, and I happen to disagree with that and there
are a number of things that you mention in your testimony that
appear to indicate that you would agree with me on this issue.
What role should the Federal Government play with respect to
health disparities and how can we, at this level, make a
difference?
Mr. Ruffin. Mr. Chairman, I think that some of the programs
that I mention in my testimony, in particular I would like to
emphasize the loan repayment program and I would like to use
what we have learned just from, say, the AIDS research that we
have conducted at the National Institutes of Health. I have
been at NIH now 19 years so I remember when the AIDS loan
repayment program was put in place, and I can tell you that
much of what we have learned about AIDS, that we would not have
known about AIDS if we had not put that loan repayment program
in place. In fact, what we said to doctors was that if you were
to come to the NIH and conduct research, we will pay off your
loans. That program has been very successful and much of the
data that we have gathered has been proof of that.
I think that if we are going to do anything about health
disparities, I really think that it is going to start with a
strong workforce. That is what we need, and I think that what
we have to do is to put in place a program that goes after the
best and the brightest people and say, if you were to go into
health disparities and help us to solve some of these problems,
we will pay off some of these loans that you have. That is what
was mandated to us by Public Law 106 09525 and it is paying
off. I don't think that it is just the Federal Government's
responsibility. I think that it is going to have to be the
responsibility of a broad segment of our society.
Mr. Pallone. But now you are talking about people going
into this disparities issue, or just the need for minority
representation in healthcare?
Mr. Ruffin. I think it cuts across the spectrum because
when you look at our loan repayment program now, that program
cuts across the entire health spectrum, not just for
physicians, physicians, Ph.D.s, dental, nursing.
Mr. Pallone. Right.
Mr. Ruffin. Sociology, Psychology, as long as they go into
the health profession.
Mr. Pallone. I am amazed, we had--I don't know if it was
this year, whenever we had a hearing on Indian healthcare and
the number--I think there was some ridiculous number like 400
Indian American physicians in the whole country, less than 500
for the whole country. It is just amazing how for some
populations and in some of these health care professions, there
are so few, there is so little representation. Did you want to
comment on this Dr. Graham?
Dr. Graham. Yes and actually that points back to that
earlier point when you alluded to some of the training programs
that we have been sponsoring and hopefully provide. You touched
on a very, very important issue and I want to as well support
Dr. Ruffin's statement. This issue of workforce diversity is
critical to the reduction elimination of health disparities.
The numbers that we have in terms of Native American, Hispanic,
African American physicians who are either practicing or even
if you look at just medical school faculty, in terms of other
kinds of training, even if you look at the nursing profession,
we see even more challenging numbers. Those are numbers that we
need to tackle head on, and we need to be able to address those
pipeline issues looking from not just when kids get into
college, but be able to reach out to them even in high school
and earlier so that they understand the benefits of entering
health professions and create a supportive environment so that
they can truly make their way through the pipeline. And I would
have to say that institutions that train--historically black
colleges and universities, HSIs and other institutions that
help to train--these providers are very, very important and we
have to continue to support them.
Mr. Pallone. Well thank you both. Mr. Deal.
Mr. Deal. Thank you. I want to thank both gentlemen for
being here today. And Dr. Ruffin, I agree with you that the
workforce is, perhaps, the most critical ingredient in this
whole picture and my State, of course, has Morehouse School of
Medicine and I think it is one of the institutions that you
mentioned in the programs that you help support and I thank you
for that. I think they do an excellent job of training
primarily minority physicians but they have a broader impact in
our State and in our economy as a whole. Dr. Graham, let me ask
you this: do you believe that the Office of Minority Health
that you are involved in is adequately addressing this issue of
health disparities?
Dr. Graham. I think we are. I think we have a dedicated
staff and a dedicated team of individuals who historically,
through the years have been working very hard to address this
issue of health disparities. And I think we have been focusing
our efforts now on not just those traditional areas around
workforce diversity and some of the things we talked about
here, but as I alluded to looking at how we develop new areas
around health information technology, emergency preparedness
and other emerging problems that we know are at the forefront
around health disparities.
Mr. Deal. Well, one of the concerns that some of us have
with this legislation is that since we already have the Office
of Minority Health within Health and Human Services is that the
legislation would create minority health agencies within each
agency of HHS. Some of us have concern that this would just be
another example of excessive bureaucracy overlaying what we
already have. Do you have any thoughts on that?
Dr. Graham. Well, I can't speak to the specifics of the
legislation from the position that I am in, but I can say that
we look to work with partners within HHS and across various
State and other agencies, so efforts to strengthen our
partnerships, we fully encourage, but I am going to refrain
from speaking specific on the legislation.
Mr. Deal. OK. One of the things that I think both of you
have eluded to is this issue of developing a workforce and I am
glad to hear you mention that we need to go beyond just the med
school level or the nursing school level. We need to get young
people interested in going into healthcare careers. One of the
encouraging things I have seen in my community is, our
education system now is beginning at the high school level to
begin to emphasize these career paths, not just for minorities
but for everybody. One of the great difficulties in a rural
district such as mine, and mine is in some ways very much like
Congressman Moran talked about, a rural area, is that we are
increasingly depending on foreign educated doctors to service
our healthcare needs. And I just think that is something that
we ought to correct and we can correct it by improving the
basic educational skills of our young people of all races in
elementary and secondary and then encouraging them and making
the opportunities available for them to go into healthcare
related careers. And so I commend both of you and your
organizations for what you do and I would be glad for you to
elaborate on further as that issue presents itself.
Mr. Ruffin. Well, I think you are right and I think that in
order to do that, what we need to do is to collaborate more.
Collaboration and partnership is going to be the key there
because many of our agencies all have a specific mission. If
you look at training at the National Institutes of Health, for
example, if you look at our total training portfolio you will
find that at the undergraduate level, the graduate level,
moving forward NIH has a very strong portfolio. If you were on
the other hand, though, to look at K through 12 education, you
are not going to see much in the way of training there, but
here is what we need to do and this is what we are doing. We
need to collaborate with other agencies whose portfolio is
bigger. The National Science Foundation, for example does a lot
as it relates to K through 12 education. We have formed
partnerships with the National Science Foundation and
essentially what we are saying to them is that you, for
example, you do the engineering and you do the math, and we
will do the life science and we will work together in terms of
putting programs together across agencies. So, we can't just
work within our individual silos, i.e., we have 27 institutes
and centers at the National Institutes of Health and we have
learned a lot about partnering within the agency. We have to
also learn a little bit about partnering and collaborating
across agencies.
Mr. Deal. I agree with you and I am glad to hear that you
are doing that and I thank you, both of you gentlemen, for
being with us today. I yield back my time, Mr. Chairman.
Mr. Pallone. Thank you, Mr. Deal. Next is the gentlewoman
from California, who is also the sponsor of this legislation
and I have to say has been working on this bill for a long time
and really highlighting it to her colleagues, Ms. Solis.
Ms. Solis. Thank you, Mr. Chairman, and I do want to just
state that earlier in the hearing we heard from members on the
other side of the aisle mentioning that it was somewhat
unnecessary for us to have this debate and this discussion on
this particular issue, and I just want to for the record say
that I cannot agree with that. I think that this is a very
timely issue and it is integrated in all of our healthcare
systems. It is an impact that is so profound that I believe
that in the upcoming session that this should be a priority for
us to look at because it does involve all segments of our
society whether you have smaller pockets of low-income whites
or if you have an increasing rural population, or you see
migration issues occurring across the country, you are going to
be impacted one way or another by the disparate treatment in
healthcare delivery in our overall healthcare system. So, I
wanted to make that clear for the audience because there was a
statement made earlier by a member on the other side of the
aisle.
But I do want to focus my attention and questioning with
Dr. Ruffin regarding some of the loan repayment programs that
you talked about. Can you please go over with me, again, the
number of slots that exist? You mentioned there were different
percentages for different groups. How much of a change have you
seen in the last, say, 10 years in this area?
Mr. Ruffin. The changes have been immense just from the
numbers. What we have to do a better job of is making sure that
we reflect the diversity of the populations that we want. In
fact, I mentioned to you that when you look at our funding
portfolio now the vast majority of the individuals are
Caucasians. We have about 34 percent African Americans, about
14 percent, only about 2 percent Native Americans in that
portfolio, and about 9 percent when we get to the Asian Pacific
Islanders populations. We have to increase those numbers. That
is recruitment. We have to say to all of our societies and all
of the various organizations out there to assist us, but this
to me is the best thing since sliced bread because we are
saying to folks, if you come in and you do health disparities
research, then we fund you. Now, the amount depends upon the
loan debt that the individuals have--
Ms. Solis. But has the number grown? I mean, the 1,400 that
you mentioned, has that grown?
Mr. Ruffin. We have 1,400 that have just about graduated
from the program. We have about 1,200 that are in the program
currently.
Ms. Solis. One-thousand two-hundred.
Mr. Ruffin. And then we have about 600 applications that we
are now in the process of screening.
Ms. Solis. And has that number been consistent over the
last 5 years?
Mr. Ruffin. No, that number is increasing.
Ms. Solis. Where was it 5 years ago, as an example?
Mr. Ruffin. I would say that 5 years ago the numbers would
have been somewhere around 600 and now we are talking, now, in
terms of the number of applications that we may have received,
the numbers may have been higher, but the caliber of applicants
that we are looking for, the best and the brightest, that
number is increasing as well.
Ms. Solis. Would you say that there is a need to increase
those slots?
Mr. Ruffin. I think that we need to do two things. I think
that we need to increase the number of slots, but in addition
to increasing the number of slots, and we are beginning to do
this too, we have to think about the other end of the spectrum,
i.e., what are these individuals going to do once they finish
the loan repayment program? After all, the program was not
created just to pay off the loan.
Ms. Solis. Dr. Ruffin, if I could just interrupt you. How
many of those slots are actually for research in disparities, I
mean?
Mr. Ruffin. All of them.
Ms. Solis. All of these you are talking about?
Mr. Ruffin. That is a prerequisite for the loan repayment
program.
Ms. Solis. And under the Title 7 program, we also have the
ability to assist young people and create career opportunities
there. What proportion of that have been set aside for
disparities research?
Mr. Ruffin. Well the Title 7 program, the main part of that
that impacts our office has been the endowment program, because
when the endowment program was created it was created in
concert with HRSA, and so the prerequisite for an endowment
program is that you must have a COE, you must have a Center of
Excellence, and so that is a partnership between NIH and HRSA.
And right now only about 16 institutions have those programs.
Ms. Solis. Sixteen, and does that include Hispanic- and
Black-serving institutions?
Mr. Ruffin. Yes, and not only that but also Native American
institutions as well.
Ms. Solis. One of the concerns or issues that has presented
itself to some of us is the way to do non-traditional outreach,
that is for some of the institutions to partner with CBOs or
recognized groups that are actually in the business of doing
this work and identifying that core population of potential
labor force that you are looking at.
Mr. Ruffin. Right.
Ms. Solis. Is that something that might be of interest to
your--
Mr. Ruffin. Not only of interest, but if you go back to
part of my statement that dealt with the community based
participatory research program, that program incorporates the
very element that you are discussing, because the community can
drive that particular program activity.
Ms. Solis. And have there been grants given?
Mr. Ruffin. Yes.
Ms. Solis. There have?
Mr. Ruffin. The interesting thing about that program, if I
can say it quickly, is that it has three parts to it, three
phases to it. It is funded for 3 years so that you get your
partners together and you talk, because this is not a program
where there is just one size fit all. It depends on the
activity in that community. So, the first 3 years is a planning
period. After the planning period, you get a 5 year research
phase, participatory phase, and then 3 years to get that
information into the community. So, if you look at it, that is
5 plus 3, that is 8, 9 10, 11 years of support if one is
successful in that particular arena.
Ms. Solis. Can you provide the Committee with information
about that and exactly where we are?
Mr. Ruffin. Absolutely.
Ms. Solis. That would be very important.
Mr. Ruffin. Yes,
Ms. Solis. Has my time run out? I am sorry, I believe we
can go for another round, or we will submit questions to you.
Mr. Ruffin. Fantastic.
Mr. Pallone. I was going to move forward to the third
panel, unless--OK. This is such a crazy day. We appreciate your
testimony and answering our questions and I know, in
particular, you had to change your schedule, so thanks a lot.
You may get additional questions in writing within the next 10
days that the clerk will submit to you and of course we would
appreciate if you would respond to them, but thank you very
much.
Mr. Ruffin. Be my pleasure.
Dr. Graham. Thank you very much.
Mr. Pallone. And then I would ask the third panel to come
forward if you would. I know we have a large group, but if you
could come forward and take your seats. Do we have the name
tags up there? Have name tags for the others? I know we have a
large panel today, but let me introduce everybody from left to
right. First of all is, from my own state of New Jersey and
from my district, actually, is Dr. Risa Lavizzo-Mourey, who is
President and CEO of the Robert Wood Johnson Foundation. It
says Princeton, but I will put you in New Brunswick, if that is
all right. And then, next to her is Dr.--I am sorry, yes, Dr.
James Edwards, who is Adjunct Fellow of the Hudson Institute in
Arlington. And then we have Dr. Mohammad Akhter, Executive
Director of the National Medical Association. And then we have
Dr. Sally Satel, who is with the American Enterprise Institute.
And we have Ms. Janet Murguia, who is President and CEO of
National Council of La Raza, here in Washington. And then we
have Mr. Bruce Lesley, who is President of First Focus, and Dr.
Theodore Knatt of the Greater Baton Rouge Musculoskeletal
Group, in Baton Rouge, obviously. And last is Deeana Jang, who
is a Policy Director for the Asian and Pacific Islander
American Health Forum. Thank you all for being here today. You
know the drill. We have 5-minute opening statements that become
part of the record, and in the discretion of the Committee, we
may submit additional questions, in writing, that we would ask
you to get back to us about. But I will start with Dr. Lavizzo-
Mourey. Thank you for being here. I don't know if that is on,
or maybe you need to move it closer to you.
Dr. Lavizzo-Mourey. How is that? Better?
Mr. Pallone. That is better.
STATEMENT OF RISA LAVIZZO-MOUREY, M.D., M.B.A., PRESIDENT AND
CEO, ROBERT WOOD JOHNSON FOUNDATION
Dr. Lavizzo-Mourey. I want to thank you for the opportunity
to submit testimony for this important issue on disparities in
health and healthcare and for the opportunity to express my
support for the Health Equity and Accountability Act. As you
have already noted, I am Dr. Risa Lavizzo-Mourey, President and
CEO of the Robert Wood Johnson Foundation, the Nation's largest
philanthropy devoted exclusively to improving the health and
healthcare of all Americans.
As a philanthropy committed to producing measurable impact,
the challenges we face in health and healthcare are formidable
and are often interrelated. Like you, we have to think about
these challenges on a number of levels. For example, we
recognize that Americans' health results from different
factors, like personal behaviors and factors such as housing
and education. We also recognize that getting good care is a
matter of both access and the quality of care that is available
in a person's local community.
In order to make good on our commitment to improve health
and healthcare for all Americans, we cannot ignore the evidence
that certain groups persistently suffer worse health and worse
healthcare. I had the honor of serving as the Vice Chair of the
Institute of Medicine's Committee that produced the 2002
report, Unequal Treatment. We reviewed hundreds of research
studies documenting gaps in care between blacks, Hispanics and
whites, and it was indeed sobering. We found that racial and
ethnic disparities in care persist even when other factors such
as health insurance and income levels are equal. We also know
that there are marked racial and ethnic disparities in
devastating outcomes of care.
The Robert Wood Johnson Foundation recently commissioned a
report by the Dartmouth Atlas Project that found considerable
variation in care by region and by race. Perhaps, most
striking, this research showed that the rate of leg amputation,
nationally, is four times greater for black Medicare patients
with diabetes than for white Medicare patients with diabetes.
When we released this data we got a lot of questions. What is
at fault? Who is to blame? Why are the amputation rates higher
for one group over another? Is this personal health behaviors
or is it the system? Our answer is that there is no single
cause behind this devastating outcome. Rather, it comes from a
number of things that progress over time, and we as a Nation
must focus on comprehensive solutions.
So, how does one begin to think about closing these gaps in
health and healthcare? To illustrate the point, I am going to
ask a question. How do the amputation rates for Hispanic
patients compare to those of non-Hispanic black or non-Hispanic
white patients? The answer is, we don't know. The Medicare data
don't tell us the answer for Hispanics, for Asians, for Native
Americans. The processing of Medicare claims does not yield
information of this sort and the data tell us only about
differences between blacks and whites in the levels of care
that they get. The Health Equity and Accountability Act would
change that, ensuring the collection of data on both race and
ethnicity, as well as primary language.
At the Robert Wood Johnson Foundation we have taken the
approach to data collection in several stages. We have looked
at the legal aspect, showing that Medicare can do much more in
standardizing data collection on race and ethnicity. However,
data collection is only one step. We also have to show that
healthcare institutions serving high numbers of minority
patients can improve and we have, in fact, seen that. In 2005,
our Foundation launched a program called Expecting Success, a
program specifically aimed at improving cardiac care for
minority patients in hospitals. Now, many hospitals were
surprised to see stark gaps in the levels of care they were
providing to different patient groups. For example, one
hospital found a big difference in non-Hispanic patients and
Hispanic patients when it came to handling critical information
at the point of discharge. They took steps to address the gap
by looking at what was happening as patients left the hospital
and making sure that discharge instructions were given in
Spanish. These seemingly straightforward and simple measures--
measure the quality by race and ethnicity, implement
interventions designed to improve the quality of care, and then
measure again--show that we can make a difference. But data
collection identifying the disparity is critical to making
these improvements.
Another essential step in improving the quality and
availability of healthcare is language services for patients
with limited English proficiency. Poor communication can lead
to devastating and deadly consequences for patients, and with
nearly 20 percent of the Nations population speaking a language
other than English at home, it is critical that our healthcare
system meet their needs.
In short, I want to express my support of the Health Equity
and Accountability Act and note that we are committed to moving
forward with you as partners and to continuing our efforts to
bring other critical partners as we strive to improve health
and healthcare for all Americans. Thank you.
[The prepared statement of Dr. Lavizzo-Mourey follows:]
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Mr. Pallone. Thank you, Doctor. Dr. Edwards.
STATEMENT OF JAMES R. EDWARDS, JR., ADJUNCT FELLOW, HUDSON
INSTITUTE
Mr. Edwards. Thank you, Mr. Chairman, and thank you for the
opportunity to comment on H.R. 3014. Because of time
limitations I will focus my remarks on Section 503. This
section lets States provide Medicaid to what could be termed an
unartfully described class. It extends eligibility to, quote,
``undocumented residents who are lawfully residing in the
United States.'' That description is kind of curious, since the
Federal Government issues documents to every legal immigrant
and non-immigrant visa holder, or requires them to have a valid
visa with an entry stamp. This new category is vague and
therefore prone to abuse.
Who would be covered under this description? It seems to
describe one-time illegal aliens who have managed to delay
their removal. ``Undocumented resident'' is a term usually
referring to illegal aliens. They have no valid document
authorizing their presence in the United States. Illegal aliens
delay or avoid deportation by requesting formal removal
proceedings or by filing an application to adjust their status
to lawful permanent resident, a non-immigrant category, or
asylum. Since aliens can't be deported until final
determination in their formal removal process, adjustment
application or asylum claim, it could be argued that these
aliens are technically ``lawfully residing in the United
States.''
Welfare reform barred non-immigrants, that is, temporary
visa holders, and illegal aliens from means-tested programs,
including Medicaid. So, H.R. 3014 loosens the qualifications
for people under the definition above of questionable legality.
This would seem unfair to lawful immigrants who abided by the
law to get here and must rely on their sponsor for their
financial well-being. Green card holders are barred from
Medicaid for 5 years, as both they and their sponsors agreed in
a legally binding affidavit of support. This section also
explicitly exempts ``any sponsor'' of these ``undocumented
residents'' from their liability to repay the medical cost
imposed on the public. This financial liability is sworn,
legally enforceable debt that was willingly agreed to. So, this
section goes backwards on the principle of individual
responsibility.
If a legalization bill were to pass, then under this
definition in this section, it might multiply greatly the
number of beneficiaries. Under every recent amnesty plan
illegal aliens would receive some sort of interim status while
waiting for longer term documentation. They would now be
``lawfully residing in the United States.'' The consequences
and costs and impact on medical resources would be serious.
Also, Section 503 could potentially spur fraud and abuse.
The bill's flimsy description of who qualifies adds an
incentive to enter or remain in the country illegally, to
perpetrate immigration benefit fraud or both. Immigration
benefits fraud is already rampant. It costs American taxpayers
and it adds to the already lengthy time that law-abiding
immigrants must wait for visas. This provision diminishes a
principle whose essence is promoting individual responsibility
and self sufficiency. It is called public charge doctrine. A
public charge is someone who cannot or will not support
himself. Since the 17th century, colonies, then States and
Federal Law have excluded foreigners likely to depend on the
public's resources. They have required ship's manifests to be
given up front. They have required posting bond for potential
public charges or even returning passengers at the ship's
captain's expense. Immigrants have normally been held to the
standard of self sufficiency that we expect of our fellow
Americans. The 1996 Immigration and Welfare Reforms were true
to that standard.
This bill shouldn't move without coupling it with at least
one of a couple of other bills that would help mitigate the
potential harm of the bill in question today. Ranking Member
Deal's H.R. 1940, the Birthright Citizenship Act, would end
automatic U.S. citizenship to the newborns of illegal aliens.
The other bill, H.R. 938, is the Nuclear Family Priority Act.
It would enact the recommendations of the Barbara Jordan
Commission. It would eliminate chain migration visas and place
priority on reunifying spouses and minor children. In summary,
H.R. 3014 may be well intentioned, most of us would like to see
reductions in health disparities and expansion of health
information technology, but it needs some work at this point.
[The prepared statement of Mr. Edwards follows:]
Statement of James R. Edwards, Jr.
Thank you for the opportunity to comment on H.R. 3014, the
Health Equity and Accountability Act. This is wide-reaching
legislation and perhaps overly ambitious, given that some of
its proposals are likely to reap untold consequences. This bill
falls at the intersection of welfare, health care, and
immigration policy. Any one of these is difficult to craft
prudently and responsibly, so as to minimize adverse effects.
Attempting to delve into all three policy areas at once could
well prove risky.
I will focus my remarks on Section 503 of this bill, as
well as translation provisions. I will place the first section
in broader, historical context.
This section would amend both Medicaid and the State
Children's Health Insurance Program statutes. States could opt
to provide medical care through Medicaid to an unartfully
described class. Waiving the 1996 Welfare Reform Act's bar on
immigrant eligibility for taxpayer-funded welfare programs, in
this case Medicaid, this bill extends this entitlement
eligibility to ``undocumented residents who are lawfully
residing in the United States.'' For anyone involved in
immigration policy, that description is curious, to say the
least, since every legal immigrant and nonimmigrant visa holder
is either issued documents by the Federal Government or
required to possess a valid visa with an entry stamp. This new
category is unacceptably vague and, therefore, dangerously
abuse-prone.
Who is this curious group? It would seem a description of
one-time illegal aliens who have managed to secure an interest
in a bureaucratic process, which delays their removal. As you
know, ``undocumented alien'' or ``undocumented resident''
usually is a euphemism for illegal alien. This could be someone
who unlawfully crossed the border or who arrived on a valid,
temporary visa and never left when the visa expired. Thus, such
people would be ``undocumented''--they have no valid
immigration or other document authorizing their presence in the
United States. Illegal aliens may seek to delay or avoid
deportation or prosecution by requesting formal removal
proceedings rather than voluntary departure, or by filing an
application to adjust their status to some other category, such
as lawful permanent residence (a ``green card"), one of the
many temporary nonimmigrant categories, or asylum. Since aliens
may not be deported until their formal removal, adjustment
application, or asylum claim is processed and a final
determination is made, it could be argued that these aliens are
technically ``lawfully residing in the United States.'' Without
further clarification, however, this category is open to
interpretation.
The Medicaid expansion further specifies that welfare
eligibility is to be extended to ``pregnant women,'' during and
for 2 months following the term of their pregnancy. It should
be noted that HHS regulations on SCHIP issued in 2002 already
provide for prenatal care to fetuses of illegal aliens; so, the
care is already available to unborn babies and their pregnant
mothers, and this provision is unnecessary. This bill also
qualifies ``children'' under age 21, which would include people
old enough to drive, to vote, in many states to drink alcohol,
and to enlist in the military.
It is important to note that welfare reform barred
nonimmigrants (or holders of temporary visas) and illegal
aliens from means-tested programs, including Medicaid. So, H.R.
3014 rolls back welfare reform by loosening up the
qualifications for people of highly questionable legality. This
seems fundamentally unfair to lawful immigrants, who abided by
the law to get here and must rely on their sponsor, not the
government or the American taxpayer, for their financial well-
being. Green card holders are barred from Medicaid for five
years, as both they and their sponsors agreed in a legally
binding affidavit of support. The exception written in this
section seems to take the guise of ``compassion'' to mask
unfairness--toward working Americans, taxpayers, and lawful
immigrants.
The next provision of this section explicitly exempts ``any
sponsor'' of these ``undocumented residents'' from their
liability to repay the medical costs these people will impose
on the public treasury. This financial liability is sworn,
legally enforceable debt willingly agreed to as a condition of
the American people's generosity in allowing sponsored aliens
the privilege of residing in our Nation. This bill undermines
the clear principles of individual responsibility and balance
that welfare reform put into place.
Importantly, if any legalization bill were to pass, it
would apparently multiply greatly the number of people who
would qualify under this poorly worded eligibility category.
Under every major amnesty plan discussed in the past several
years, illegal aliens would receive some sort of interim status
while waiting for longer term documentation. This would mean
these ``undocumented'' residents were now ``lawfully residing
in the United States.'' The consequences, the costs, the impact
of added demand on scarce medical resources in every locality
would be serious.
Another important concern with regard to Section 503 is the
incentive for fraud and abuse that it creates. The flimsy
description of who qualifies for Medicaid adds yet another
incentive to enter or remain in the country illegally, to
perpetrate what is known as ``immigration benefits fraud,'' or
both. Immigration benefits fraud is one of the most unsung, but
heavily abused areas where our immigration laws are broken. It
results in additional costs to American taxpayers, and it adds
to the already lengthy times that law-abiding immigrants and
nonimmigrants must wait to receive their visas, since it
diverts personnel and resources at U.S. Citizenship and
Immigration Services (USCIS). This provision compounds that
problem and would likely lead to more of this fraud.
Given the uncertainty in and open-ended nature of the
description of who would qualify under H.R. 3014 Section 503,
it is hazardous to guess how much this provision will cost
taxpayers. A provision similar to this section was in the CHAMP
Act, H.R. 3162. It extended Medicaid and SCHIP coverage to
lawfully permanent resident pregnant women and children up to
age 19. The Congressional Budget Office scored that provision,
Section 132, at $2.2 billion over 10 years. The state spending
that provision would require nearly doubled the cost. Four
billion dollars is a significant amount. One would expect costs
at least as great, if not greater, than CHAMP. I would urge
lawmakers to question the advisability of extending any
entitlement program, such as Medicaid. Such is an open-ended
commitment. At a time when entitlement programs--Medicare,
Medicaid, and Social Security--careen on a course of fiscal
unsustainability and overwhelming debt, would it not seem
fiscally irresponsible to compound the unfunded liability
exposure? Rather, prudence would dictate reducing financial
liability and narrowing program eligibility.
Stepping back a bit, this provision, and other parts of the
bill, diminishes one of the oldest, central principles of
American immigration law--a principle whose essence is
promoting individual responsibility and self-sufficiency:
public charge doctrine.
A ``public charge'' is someone who cannot or will not
support himself and instead is reliant on society.
Massachusetts adopted the earliest American public charge laws,
in 1645. The colonies protected themselves against public
charges by excluding, or refusing to allow to settle, people
who were regarded as likely to become dependent on the public's
resources. Colonies required arriving ships to provide the list
of passengers or required that ship captains post bonds for
potential public charges. Otherwise, the ship had to return the
``lame, impotent, or infirm'' passengers ``incapable of
maintaining themselves.'' These types of colonial laws were
incorporated as state laws following American independence.
Over time, as Congress became more active in making immigration
policy, Congress and states acted concurrently to bar likely
public charges or to deport immigrants who became public
charges. By the late 19th century, Congress took on the
responsibility of setting immigration policy, and promptly
enacted in the 1882 Immigration Act the exclusion of any
immigrant ``unable to take care of himself or herself without
becoming a public charge.''
The reason for such a ``tough love'' standard is
compassion, properly understood, toward the native-born and
capable immigrants. They must work harder, pay more taxes (or
health insurance premiums), etc., to subsidize people who
otherwise would not live here; it is the same as Captain John
Smith's ``tough love'' rule in Jamestown, Virginia, that those
new arrivals who were not willing to work and pull their weight
were excluded from meals.
This section of H.R. 3014 swims against the stream of our
history. It weakens public charge doctrine. It diminishes the
concept that America is the land of opportunity for those we,
the American people, decide to admit. We have traditionally
rejected the idea that Americans should have to accept all
comers or materially support immigrants. No, immigrants have
normally been held to the standard of self-reliance that we
expect of our fellow Americans.
The 1996 immigration law (Public Law 104 09208) and welfare
reform (Public Law 104 09193) remained true to and strengthened
that venerable standard. These laws required: most immigrants,
relationally based and employment-based accompanying family
members, must secure an affidavit of support from the sponsor.
The affidavit of support, which a sponsor signs accepting
financial responsibility for an immigration applicant, became
legally binding. Sponsor income must be at least 125 percent of
the federal poverty line. All sponsor income is ``deemed'' as
available to the immigrant. Government agencies could seek
reimbursement of the costs the sponsored alien imposes on the
taxpayer, until the sponsored alien naturalizes or has
established a 10-year work history. The legislation that is the
subject of this hearing substitutes an opposite standard.
Briefly please allow me to touch on the bill's translation
provisions. First, Medicaid already covers translator services.
So, this appears an unnecessary addition. Second, there could
be unintended consequences. Medicaid already provides very low
provider reimbursements, less than actual costs. Thus, in
certain locations Medicaid has difficulty attracting doctors to
see Medicaid patients. Adding translation mandates could force
more providers to decline acceptance of new Medicaid patients.
The American Medical Association has voiced this very
concern, the reduction of access due to government-mandated
translation services:
. . . It is extremely inequitable to require physicians to fund
written and oral interpretation services. The cost of hiring an
interpreter, which our state survey shows can greatly vary
between $30 and $400, is significantly higher than the payment
for a Medicaid office visit, which in many states ranges
between $30 and $50. Physicians would sustain severe economic
losses if forced to cover the cost of interpretation services
and thus may no longer be able to provide services to LEP
[limited English proficient] patients. Indeed, AMA data shows
that two-thirds of physician offices are small business. If a
business, especially a small business, continues to lose
revenue and begins to operate on a negative balance sheet, the
business cannot be maintained.
The AMA noted the cost differential between the costs
doctors bear and revenue from Medicaid, the difficulty finding
interpreters in many states, and impracticalities such as
cancelled appointments where arrangements were made to secure
an interpreter (who still expects to be paid for his or her
time). The potential for these kinds of factors do not seem to
have been fully contemplated in H.R. 3014.
Further, Section 101 translation provisions effectively
codify Executive Order 13166. This very controversial order
directs every Federal agency to provide ``access to federally
conducted or federally assisted programs for persons who, as a
result of national origin, are limited in their English
proficiency.'' Executive Order 13166 amounts to an unfunded
mandate on hospitals, public health clinics, and health care
providers who receive federal funds. Also, the government uses
a highly suspect definition of ``limited English proficient,''
which can unnecessarily escalate the costs to taxpayers. The
definition should generally be fixed so interpreter and
multilingual materials mandates apply only in common-sense ways
and only assist those who in fact do not speak English ``very
well.'' The other impact of these policies is to work against
assimilation. They cool the melting pot, whereby people from
other lands learn to speak English, adopt American political
virtues, and become, in Lincoln's words, ``blood of the blood,
and flesh of the flesh of the men who wrote that Declaration
[of Independence].''
Should the committee choose to move this legislation, in
addition to addressing the matters I have raised, the bill
should not be enacted without coupling it with at least one of
two other bills. Either of these other bills would mitigate the
potential harm caused by H.R. 3014. Ranking Member Deal's H.R.
1940, the Birthright Citizenship Act, would eliminate the
incentive some illegal aliens have of birthing their offspring
in the United States. The policy of granting automatic U.S.
citizenship to the ``anchor baby'' effectively foils the
parent's deportation, qualifies the illegal parent to derive
benefits accorded to the newborn based on his or her
citizenship, and allows that illegal alien to begin his own
chain of relatives once the citizen child turns 21. The child
can sponsor the illegal alien mother, as well as extended
relatives. Ending automatic citizenship on account of birth
here would help alleviate this abuse. The other bill that
should accompany this legislation is H.R. 938, the Nuclear
Family Priority Act. Congressman Gingrey's bill would enact the
recommendations of the Barbara Jordan Commission. It would
eliminate extended relative visa categories (chain migration
visas), instead placing priority on the nuclear family's
reunification: spouses and minor children. Without one or both
of these bills as counterbalance, H.R. 3014 should not move at
all.
In summary, in 1996, a Democratic President and a
Republican Congress came to agreement on landmark immigration
and welfare reform legislation. That bipartisan accomplishment
was not easy. Sadly, H.R. 3014 seems to fall short of that
model. This bill may be well intentioned--most of us would like
to see reductions in disparities in the health of minorities
and other demographic subgroups, expansion of the reach of
health information technology, especially to rural areas, and
so forth. But H.R. 3014 goes about it in certain ways that are
more divisive than unifying.
# # #
----------
Mr. Pallone. Thank you Dr. Edwards. Dr. Akhter.
STATEMENT OF MOHAMMAD N. AKHTER, M.D., M.P.H., EXECUTIVE
DIRECTOR, NATIONAL MEDICAL ASSOCIATION
Dr. Akhter. Thank you, Mr. Chairman, members of the
Committee. It is an honor to appear before you. My name is
Mohammad Akhter. I am Executive Director of the National
Medical Association. The National Medical Association is an
organization of African American physicians, 30,000 of them
strong, in this country, serving the minority communities all
over the United States. This issue is very important to us. In
addition to myself, the President of the National Medical
Association, Dr. Nelson Adams, is also in the audience because
we believe that over the 200 years history--plus history of
this Nation, our community has suffered the most from health
disparities. Our people have been dying much younger than the
others. Our people suffer from many more chronic diseases than
others, so this is a very timely bill. This is to be commended,
Mr. Chairman, members of the Committee, for having this bill at
this particular time so that we could have the discussion and
debate to move this country forward.
I would like to make four basic observations about the
bill, why this bill is so timely and so important. The first
thing is that this bill requires the data collection. If we are
not collecting the data, we don't know what the problem is. If
we are not collecting it by race, we are not collecting it by
language, we just don't know what the problem is. We can't
design the right programs, we can't evaluate the success of the
program to see if the program is going in the right direction.
So, the first and fundamental thing is to really continue to
have a system in place that monitors and evaluates the program
and health of our people.
The second thing that this bill does, it strengthens the
government agencies that are already involved in elimination of
health disparities. As is very evident that we can see, Dr.
Garth Graham testified before us and so did Dr. Ruffin that
these agencies need to be strengthened because their work is
incomplete. They have a lot more work that needs to be done and
in addition, other government agencies such as CDC, the Social
Security Administration and others need to participate in this
effort to really start to collect the data so we could have a
Nation where we know what is going on in terms of the health
status of our people.
The third issue that we like this thing is particularly
because it provides and improves the health services to the
people. Lack of access to care and poor quality of care are two
big elements in creating disparities. In many cases we know
about the African American community. One out of every four
African Americans is uninsured. One out of every three Hispanic
Americans is uninsured. They don't have access to care and if
we can improve the access to care and improve the quality of
care that the people receive it will go a long way in
eliminating the disparities.
And, finally, the last issue deals with the workforce.
Hispanic community and African American community people of
color constitute 25 percent of all Americans, but we have only
6 percent of the Nation's doctors. Many studies have shown that
when the doctors speak the same language, when the doctor is
familiar with the culture of the patient, there is better
patient-physician communication. There is better relationship.
There is better compliance. There is better acceptance of the
treatment. Patients get well soon and these are very important
things. If we can't do that, then we need to have cultural
competency so that the other providers become aware of other
patients' cultures and provide them with appropriate treatment.
This bill provides for creating the cultural competency and
providing the good care.
And, finally, as an immigrant, I will tell you, America is
all about the future. Somebody did such wonderful work that we
are enjoying the fruit today. In a globalized marketplace the
people who are going to succeed are the folks who have the best
educated and the best, healthiest people around. If we continue
not paying attention to the health disparities, and these
health disparities continue to persist, we are going to have
workers by 2050, the majority of the workers are going to be
the people that we call today, minorities. With sick people, we
can't compete in the work marketplace, and that will seriously
threaten the strength of the United States of America as a
Nation and will really threaten, also, our lifestyle that we
are used to. So, Mr. Chairman, members of the Committee, I beg
you, I urge you this is a timely thing for us to do as a
Nation, to take action so all Americans could have the equal
right to health, life, liberty, and happiness. Thank you, very
much and appreciate it.
[The prepared statement of Dr. Akhter follows:]
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Mr. Pallone. Thank you, Doctor. Before we move forward, we
are not going to be able to--we will try to go to as many of
you as you can, but that was the bell for the Medicare
Physicians Reimbursement bill, to vote. So, we may be able to
do a couple more and then we will have to break and go vote and
come back, just so you know. Dr. Satel.
STATEMENT OF SALLY SATEL, M.D., AMERICAN ENTERPRISE INSTITUTE
Dr. Satel. Thank you Chairman Pallone, Representative Deal,
other distinguished members. My name is Sally Satel. I am at
the American Enterprise Institute, as you mentioned. I am also
a staff psychiatrist at the Oasis Drug Treatment Clinic in
northeast Washington, D.C.
The point I would like to emphasize today is that efforts
to improve the health of minorities will be most successful
when they target the factors associated with socioeconomic
disadvantage in general. And also, that such disadvantage is
not limited to racial and ethnic groups. It applies to all
Americans living at the lower reaches of the socioeconomic
ladder. Living there has meaningful implications for one's
health. The most obvious, of course, being access to treatment
services, but that is certainly not enough. We must also work
on factors that impede the capacity of patients to get the most
out of the healthcare system once they enter it.
And the key here is engagement, and I see that as a theme
running through H.R. 3014. What do I mean by that? Well, some
aspects are obvious. Patients won't be engaged if they can't
communicate with their providers. This level, naturally,
entails language and interpreter services, a big part of the
bill. But it also entails several other things. For example, it
is very important to establish continuity of care with the same
clinician. Patients who see the same doctor, visit to visit,
have an opportunity to establish rapport, which in turn leads
to better adherence with treatment and conscientiousness about
self care.
A 2006 Commonwealth Fund Survey found those adults who have
a stable healthcare setting that provides them with timely,
well organized care and enhanced access to providers is a
setting in which racial and ethnic disparities and access and
quality are reduced or even eliminated.
In addition to the importance of continuity of care is the
aspect of simply having enough time with one's doctor. I happen
to work in a clinic where it is quite amazing. I can spend as
much time with my patients as I want, but that is because we
don't take government funding, and the standard 15 minutes,
which most doctors spend, is simply not enough to elicit
concerns, including complaints about side effects, a big reason
why compliance is often bad, the patients needs and values and
preferences. A 1994 Harris Pole, also for the Commonwealth
Fund, actually one of the largest, most detailed, and most
ethnically diverse surveys I have ever seen, asked patients
what the main complaint--they surveyed eight ethnic groups and
what was their main complaint about getting care and it was
their physicians failure to spend enough time with them. And,
of course, as you know, Medicare and Medicaid reimbursement
create disincentives against those kinds of rich clinical
encounters. Codes might be expanded to pay for a decent rate
for what we call cognitive and evaluative services to save
money down the line. Phone calls to patients between visits,
home visits by nurses, this kind of thing. Other many useful
accommodations are simple but so important: night hours, child
care on-site, patient navigators, things like this.
But accessibility and engagement are not ends in and of
them selves. They are means to empower patients to become
involved with their own self-management, and I worry that there
is not enough emphasis on the responsibility that patients have
to take, as well. Especially those with diabetes, hypertension,
asthma, cardiovascular disease, it is very hard to manage
yourself when you are poor. The grind of daily stresses without
a financial cushion and everything that comes with the chaotic
lifestyle that so many of my patients have, makes it very hard
to watch your diet and exercise and check your blood glucose,
but many patients also want to participate if we can make those
kinds of activities available to them.
I will just give two examples. Vanderbilt University has an
expert in rheumatoid diseases that has a self-help course for
patients with rheumatoid arthritis. It has led to reduction in
pain and medication and physician visits that resulted in a
savings that were 10 times the cost of that course itself.
Another example and examples of collaboration between
communities and their resources within communities are so
important. For example, there is a local community health
center in Massachusetts that has paired with the local YMCA to
enable patients with diabetes to exercise with a resulted
improvement in diabetes control. These examples illustrate why
more decentralized neighborhood-based care will be the most
responsive to needs of specific communities. The staff will be
drawn from those communities, speak the language, they will
know the culture, and this is an organic way of achieving a
more accommodating and culturally compatible health service.
In closing, reducing health differentials between racial
and ethnic groups depends, of course, on improved access to
care, quality of care, and most relevant, in my view, to
today's hearing: patient's capacity for self care. This depends
upon strengthening their engagement in treatment and this is a
strategy that applies to all underserved and low-income
Americans, irrespective of race and ethnicity. Thank you, so
much.
[The prepared statement of Dr. Satel follows:]
Statement of Sally Satel
Chairman Pallone, Representative Deal, and distinguished
members of the Committee, my name is Sally Satel. I am a
resident scholar at the American Enterprise Institute and a
lecturer at Yale University School of Medicine. I also serve as
the staff psychiatrist at the Oasis Drug Treatment Clinic in
northeast Washington D.C.
Thank you for the invitation to present my views on the
determinants of health status.
The point I would like to emphasize today is that efforts
to improve the health of minorities will be most successful
when they target the factors associated with socioeconomic
disadvantage that predispose individuals to poor health and
suboptimal care. Such disadvantage is not limited to racial or
ethnic groups.
Before turning to practical interventions that can be
deployed within the health care domain--and, indeed, there are
many--it is important to acknowledge that the clinical setting
represents only one of many realms that contributes to health.
This recognition helps frame reasonable expectations of
interventions that originate at the level of the healthcare
system.
Socioeconomic Basis of Health--``Upstream'' Factors
In a larger, social context it appears that educational
attainment is one of the strongest predictors, if not the
strongest predictor, of adult health. Failure to complete high
school in the United States is associated with a considerably
higher likelihood of developing many chronic diseases before
the age of 65 years.
Why does education create most of the association between
higher social status and higher health status? The mechanisms
are complex and not fully understood but scholars generally
believe that good education enables children to develop self-
control, problem-solving dispositions, and not least, a sense
of future. As adults, those who are well-educated feel more in
control of their lives; they have more opportunities to obtain
decent jobs, jobs with health benefits, more autonomy, and
financial security to help cushion setbacks. They are better
informed about health matters (including new technological
innovations) and tend to have a more positive view of the
benefits of such interventions. Also, better educated
individuals tend to be part of social networks that reinforce
their healthy life styles norms.
The elements of ``social capital'' briefly summarized above
serve to motivate individuals to invest in themselves (e.g., to
refrain from smoking and excessive alcohol consumption, to
exercise, observe diet, make use of preventive and primary
care, consume care in a timely manner, and so on. And the
healthier people they are, the more energetically they can
advance occupationally; the less likely they are to suffer
depression). Thus, the benefits of early education are all
encompassing and cumulative.
Practically-speaking, quality childhood education--and the
family and community circumstances that facilitate it--is not a
plausible target for a health committee, but it is nonetheless
the best single source of healthier future generations.
Nonetheless, there are interventions that individual
physicians can perform during clinical encounters that will
make an important, though an inevitably more modest,
contribution to improving health outcomes of all patients on
the lower reaches of the socioeconomic ladder.
The key to making those interventions work is the ability
to engage patients in their care. The initiatives described in
H.R. 3014 are targeted at facilitating such engagement through
improved patient-clinician communication. Patients who are more
engaged in treatment, particularly those with chronic diseases,
are more likely to take action in managing their conditions.
The end-point measure of true success will be improvement in
patient health. This health-promotion approach transcends race
and applies to all individuals of lower socioeconomic status.
Facilitating Engagement
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 or her (which, in
turn, will lead to better adherence with treatment regiment and
conscientiousness about self-care).
The Commonwealth Fund 2006 Health Care Quality Survey finds
that when adults have health insurance coverage and a stable
health care 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--Doctors must
be able to spend sufficient time with each patient--more than
the standard 15 minutes, at least --in order to elicit
patients' concerns (including complaints about side-effects),
needs, values, and preferences.
According to a 1994 Harris poll for the Commonwealth Fund--
one of the largest, most detailed and most ethnically diverse
surveys ever conducted--found that the main complaint of almost
all patients, regardless of ethnic or racial group, was the
doctors' ``failure to spend enough time with me.'' And of those
who were dissatisfied enough to change doctors, only three
percent of Asians and two percent of blacks who changed doctors
did so on the basis of the physician's race or ethnicity. The
most common complaints were ``lack of communication,'' ``didn't
like him or her,'' ``couldn't diagnose problem,'' and ``didn't
trust his or her judgment.''
Medicare and Medicaid codes should be expanded to pay (and
pay a decent rate) for cognitive, evaluative services including
activities such as phone calls to patients between visits and
home visits by nurses who will also involve the patients'
families in the monitoring process.
Cultural sensibility--Practical accommodations can help
health providers care for low-income patients of any race or
group. These include translation services and education of
medical staff about local anthropology such as healing customs,
dietary patterns, and commonly used remedies.
Take the example of black pediatrician Lynn Smitherman and
colleagues, who wrote a 2005 paper in Pediatrics entitled,
``Use of Folk Remedies Among Children in an Urban Black
Community: Remedies for Fever, Colic and Teething.'' On a radio
show she explained that she wrote the paper because she hadn't
heard of any of the remedies-her mother and grandmother did not
use any of these treatments with her when she was a child-and
assumed that many of her colleagues might not be familiar with
them either.
The importance of local customs was made compellingly clear
in an account of the...
Perhaps one of the most compelling ethnographic accounts of
the diabetes epidemic in East Harlem, New York City (Spanish
Harlem) that appeared in the New York Times (``Living at the
Epicenter of Diabetes--Defiance and Despair,'' January 10,
2006). Similarly, many black trainees or physicians may not be
any more aware of certain folk beliefs than whites.
Perhaps one of the most compelling ethnographic accounts of
the diabetes epidemic in East Harlem, New York City (Spanish
Harlem) appeared in the New York Times (``Living at the
Epicenter of Diabetes--Defiance and Despair,'' January 10,
2006).
The reporter quotes a resident of East Harlem saying:
``We've got cultural differences. Here, for a guy to eat a
salad, he's a wimp. He'll eat a big portion of rice and beans
and chicken. The women can't be chumps, either. A woman can eat
a salad but has to eat it on the low. She has to do it quiet.
They make fun of you: What are you, a rabbit?''
The article also notes that many people with Type 2
diabetes find it hard to believe they are truly sick until they
develop complications (pain, dysfunctional eyesight,
infections, etc). Only pain and disability can successfully
compete for attention in an overburdened life--and then it is
already too late.
Finally, the mere grind of being poor, the overwhelming
personal and family and occupational problems, the social
disruption and instability, and the lack of safety nets, pushes
self-care into the background. The importance of watching one's
diet, exercising, checking blood glucose, quitting smoking or
drinking, is surpassed by more pressing daily realities. Add to
this a higher likelihood of clinical depression,
demoralization, and stress in this group and the risk of non-
adherence multiplies.
Thus, it is important to create conditions in which
clinicians can spend ample time with patients to address
lifestyle issues in a cultural context in order to improve
adherence with treatment and lifestyle (diet, exercise, etc)
for which patients, themselves, bear responsibility as well.
Clinic nurses, LPNs, and support staff with whom the physicians
work are very likely to share ethnic backgrounds with the
patients because they tend to be drawn from the community in
which the patients live, as they are in my clinic in the
Northeast. To the extent that such commonality plays a role in
helping patients engage in self-management, it will enhance the
health of minority patients.
These realities strongly suggest that more decentralized
and neighborhood-based care will be most responsive to the
needs of the under-served community.
Foster health literacy to facilitate adherence with
treatment and to facilitate patient self-management and sense
of control--A patient's accurate understanding of the nature of
his illness and the purpose of various therapies and, perhaps
most important, some sense of control over his condition, 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.
It is important to assume a balance and avoid putting all
the emphasis on the clinician. As Theodore Pincus, professor of
medicine at Vanderbilt University and expert in rheumatoid
disease, has noted, ``Emphasis on the predominant role of
health professionals rather than patient actions in health
outcomes may also distract from powerful health-promoting
activities.'' He describes a self-help course for patients with
rheumatoid arthritis that led to a reduction in pain and
physician visits, resulting in savings that were 10 times the
cost of the course. The patients' improved sense of control
over their illness through self-management rather than
knowledge or changes in behavior explains the improved
outcomes. ``Patient education programs directed at reduction of
feelings of helplessness and improved self-efficacy may result
in considerably greater cost containment and better outcomes in
chronic diseases than do current efforts to restrict
medications and visits to specialists,'' he writes.
Common Sense Local Innovations--Consider other meaningful
interventions:
- Educational modules that prepare and coach patients to
ask questions and present information about themselves to their
doctors;
- Grassroots outreach through black churches, social clubs,
and worksites;
- Patient ``navigators'' to help negotiate the system;
- Clinic night hours/child care on site: 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 by Medicare and Medicaid.
Again, it is vital that healthcare systems have the
flexibility to respond to the patients they serve. The National
Association of Community Health Centers, for instance, offers
examples of innovations, including collaboration between a
community health center and a local YWCA in Massachusetts which
enabled patients with diabetes to exercise (with resultant
improvement in diabetic control).
Conclusion
Reducing health differentials between racial and ethnic
groups depends on improved access to care, quality of care,
and--most relevant to today's hearing--patients' capacity for
self-care. The latter depends upon strengthening their
engagement in treatment, a strategy that applies to all
underserved and low-income groups irrespective of race and
ethnicity.
Reiterating a point made earlier, it is important to
recognize that one of the most powerful determinants of good
health is high-quality education. A decent education can
instill in children the belief that they can shape their
futures, as well as the desire and ability to take an active
part in fostering their own good health. Once begun in
childhood, these affirmative attributes can last a lifetime,
from, say, 8 to 80.
----------
Mr. Pallone. Thank you Doctor. We are going to have to
recess. We have two votes, actually. One is on the Medicare
bill and then there is a motion to adjourn, but I understand
they are 15 minutes each, so we are talking about maybe between
the--maybe a half an hour, or so, before we come back, and
unfortunately this is what today is shaping up to be. So, we
will stand and recess for about 30 minutes until these votes
are completed.
[Recess.]
Mr. Pallone. We will reconvene. I know we don't have all
our witnesses here, but we will start with Mr. Knatt.
STATEMENT OF THEODORE KNATT, M.D., GREATER BATON ROUGE
MUSCULOSKELETAL GROUP
Dr. Knatt. Mr. Chairman Pallone, Representative Solis, I
want to thank you for having the opportunity to testify before
you. My name is Theodore Knatt. I am an orthopedic surgeon
practicing in Baton Rouge, Louisiana. I am also the Chairman
and cofounder of Greater Baton Rouge Surgical Hospital in Baton
Rouge. It is a physician owned facility that was built
primarily to provide care for the minority population to
improve the quality of care, as well as improve the quality of
the working conditions for minority physicians.
Again, I appreciate this opportunity to participate in this
hearing on healthcare disparities. I commend Representative
Hilda Solis and the 110 other members of Congress who have
cosponsored H.R. 3014 for their efforts to draw attention to
this nationwide problem and propose solutions to this complex
issue. I do not need to introduce--an introduction to the
problems of healthcare disparities. It is a daily part of my
life as a physician treating minority and low income patients.
While I can't provide any quick fix national solutions, I
can discuss what my colleagues and I do, every day, to try and
improve the quality of our patient's health and to increase
their access to medical and surgical services. We are
addressing healthcare disparities one patient at a time.
Louisiana, unfortunately, is a textbook case of the problems
that lead to healthcare disparities. Many of our citizens are
poor and others lack health insurance. Regardless of race,
poverty is a key factor in the adequacy of healthcare that
individuals receive. Race and ethnic background play a role
also. It is no secret that many African Americans do not trust
the traditional medical establishment. This is a major reason
that we built our hospital. The cultural history of our
Hispanic citizens and Native Americans also affect how they
respond to mainstream medical care. Too often, patients and
physicians are talking past one another.
Another issue, particularly in Louisiana, since the
devastation of Hurricane Katrina is the availability of medical
care. Hospitals were destroyed in the storm and many have not
been rebuilt. Physician's practices were disrupted and doctors
were moved away because the patients left. We assisted with
their recovery and took in some of those displaced patients and
physicians.
Our hospital, Greater Baton Rouge Surgical Hospital, is
predominantly owned by African American physicians. Because we
are also invested in this hospital, we are motivated to make
sure that it is safe, efficient, an economical place to deliver
medical care as well as surgical services. Also, because we own
the hospital, we have a say in its government, as well as
direct control of the care that we are providing. We help to
make administrative decisions that are needed in the best
interest of the patient. I am proud to say that the National
Medical Association is at the forefront fighting for the
resolution of healthcare disparity and recognized our facility
with the National Merit Award last year.
Prior to our development, I was totally unaware of what
difference we could make in assisting with improving healthcare
for minorities. We built our hospital to meet the medical and
surgical needs of the African American patients in the
community where we practice. Although we continue to work at
other hospitals, we wanted to create an environment of trust
for our patients and give them a sense that they were human
beings and not just numbers. Greater Baton Rouge Surgical
Hospital accepts all patients regardless of their ability to
pay.
Approximately 85 percent of our patients are African
Americans, more than 30 percent are on Medicare, about 10
percent are Medicaid, and many of these are children. That
number would be even higher if we offered obstetric care. The
balance may or may not have health insurance. We don't care.
Everyone is seen, everyone is treated. Many of our patients do
have good health insurance and could choose almost any other
facility in Baton Rouge. However, they come to us. It is our
trust factor that I mentioned earlier.
One of the great frustrations we experienced before
building this hospital was the fact that we could not provide
the kind of medical and surgical care that we thought our
patients needed. All too often, minority patients had multiple
medical problems. In addition to needing a hip or knee
replacement or repair, they are also overweight, diabetic, and
have cardiovascular challenges. Too many surgeons in too many
hospitals do not want to treat these patients, so they are told
that they are not appropriate for surgery and sent home, where
they deteriorate further.
Since building our hospital we have been able to reverse
this situation. We have established a close knit group of
physicians from many disciplines who work with us to help our
patients improve their overall health status. For example, I
often see patients in my office who need orthopedic surgery,
but the patient is also overweight, hypertensive, and has
uncontrolled diabetes. Like it or not, this is the reality of
much of minority medicine. I know that this patient is not a
good candidate for surgery at this time, but instead of sending
him or her away, I develop a plan to improve their health
status so that they can eventually get the orthopedic procedure
or surgical procedure they need. Through this network of
healthcare providers I mentioned, I get the diabetes under
control, get the hypertension properly managed.
Mr. Pallone. Dr. Knatt, if you could summarize, because you
are about 30 seconds over.
Dr. Knatt. I appreciate the opportunity to present to you a
model that has helped improve the disparity in healthcare in
Baton Rouge, Louisiana. Thank you for the opportunity to
present my testimony.
[The prepared statement of Dr. Knatt follows:]
Statement of Theodore Knatt
Mr. Chairman and Members of the Subcommittee:
My name is Theodore Knatt. I am an orthopedic surgeon
practicing in Baton Rouge, LA. I am also Chairman and cofounder
of Greater Baton Rouge Surgical Hospital, a physician owned
hospital that serves the minority population in our part of
Baton Rouge.
I appreciate the opportunity to participate in this hearing
on health disparities and H.R. 3014, the Health Equity and
Accountability Act of 2007. I commend Representative Hilda
Solis and the 110 other Members of Congress who have
cosponsored this bill for their efforts to draw attention to
this nationwide problem and propose solutions to this complex
issue. Health disparities are pervasive in our society, and it
is the obligation of all health providers to find ways to
reduce them.
This is an effort that will require support from government
at every level, active participation from all members of the
health care community, and also the efforts of those who
currently suffer the consequences of health disparities. If our
society creates improved access to medical services, then those
in need will have to take advantage of those opportunities. As
a physician, I am all too familiar with the problem of patient
compliance with the treatment regimen prescribed by their
physicians. It is a frustrating part of every doctor's work.
All too often we see patients fail to heed the advice and
counsel we have provided to them. There is no question that we
have to break down artificial barriers to good medical care,
but we must also find ways to encourage patients and families
to take advantage of what we can offer.
H.R. 3014 proposes ambitious steps to eliminate health
disparities. As a practicing physician I am not in a position
to predict whether all of them will make a difference. I only
know that my daily job is to see that my patients have access
to the care they need, when they need it. I cannot eliminate
every cause of health disparities, but I can do my best to make
sure that my efforts help my patients overcome these barriers
to good health.
I do not need an introduction to the problem of health
disparities. It is a daily part of my life as a physician
treating minority and low income patients. It was part of my
life growing up in New Iberia, LA, and one of the important
factors that made me decide to become a physician. While I
can't provide any national solutions, I can discuss what my
colleagues and I do every day to try to improve the quality of
our patients' health and to increase their access to medical
and surgical services. We are addressing health disparities one
patient at a time. While the Federal Government can play an
important role in helping reduce health disparities, unless you
can find a way to get that minority, rural, or low-income
patient directly connected to a sympathetic health care
provider, these barriers to good health will be with us for a
long time.
Louisiana unfortunately is a textbook case of the problems
that lead to health disparities. Many of our citizens are poor
and others lack health insurance. Regardless of race, poverty
is a key factor in the adequacy of healthcare that an
individual receives. It's not just the inability to pay that
causes this. Many people, even though poor, are too proud to
take ``charity'' and wait until the last possible moment before
seeking medical help.
Race and ethnic background play a role also. It is no
secret that many African Americans do not trust establishment
medicine. That is a major reason we built our hospital, as I
will explain shortly. The cultural history of our Hispanic
citizens and Native Americans also affect how they respond to
mainstream medical care. Too often, patient and physician are
talking past each other.
Physical barriers, like rivers and lakes, also keep people
from getting medical services. Now, that may be hard for the
Members of the Subcommittee to understand, since you live and
work in a city with excellent public transportation and
numerous bridges across the Potomac. In our state, however,
there is no public transportation in many areas and water is a
significant barrier, particularly if one has to travel many
miles to find a way across. I hope as the Subcommittee
considers ways to address health disparities, all of you will
make a point to see first hand where the people who experience
health disparities actually live.
Even if transportation is not an issue, custom and culture
play an important role in the way people view mainstream
medicine. As a physician trained in the latest orthopedic
techniques, I know what modern medicine can do to help people
in need. But unless we pay attention to the individual's
cultural background, those medical miracles might as well be
locked in a closet.
Another issue, particularly in Louisiana since Hurricane
Katrina, is the availability of medical care. Hospitals were
destroyed in the storm, and many have not been rebuilt.
Physician practices were disrupted, and doctors have moved away
because their patients moved away. Some areas simply do not
have a hospital and no one seems eager to come build one.
I think that H.R. 3014 tries to address many of these
issues and I know that all of you want to make progress in
reducing health disparities in this country. I understand that
legislation is the tool that you have to solve problems facing
our society. But that is your job, not mine, so perhaps the
most useful thing I can do today is tell you about our hospital
in Baton Rouge, why it was built and how we use that facility
to reduce barriers to care, one patient at a time.
Our hospital, Greater Baton Rouge Surgical Hospital, is
predominantly owned by African American physicians. We are
fortunate to share ownership with United Surgical Partners
International, Inc. They bring management and financial
expertise to our hospital. Most importantly, because they
provide essential hospital management, the physicians,
investors and non investors, are free to practice medicine and
provide care that would not otherwise be available to our
community. Because we are also invested in this hospital, we
are motivated to make sure that it is a safe, efficient and
economical place to deliver medical and surgical care. Also,
because we own the hospital and have a say in its governance,
we directly control how care is delivered and can make
administrative decisions needed for the best patient care. I am
proud to say that the National Medical Association has honored
our facility with a National Merit Award.
We built our hospital to meet the medical and surgical
needs of the African American community where we practiced.
Although we continue to work at other hospitals, we wanted to
create an environment of trust for our patients and give them a
sense that they were human beings, not numbers. One of the
major barriers that keep African Americans from seeking medical
care is the simple fact that they do not trust establishment
hospitals or health care providers who have no sense of their
cultural history, preferences or biases. My colleagues and I
knew that we could establish trust if we built our own
hospital. We have succeeded in building that trust. Many of our
patients come long distances to seek care at our facility
because they trust us.
Greater Baton Rouge Surgical Hospital has been open for 3
years. We have 10 inpatient beds, four operating rooms and one
procedure room. Our physicians perform more than 3,000
procedures annually. Interestingly, non investing physicians
refer more patients that the investors do. They have confidence
that their patients will be treated with dignity. We are in the
process of expanding our physical plant because of the patient
demand, and primary care physicians will be joining with us to
work in our clinics so we can expand the array of services we
provide. Currently we offer general surgery, gynecology,
ophthalmology, spine and hand surgery, and sports medicine. We
accept all patients, regardless of their health insurance or
economic status. Approximately 85 percent of our patients are
African American. More than 30 percent are on Medicare. About
10 percent are Medicaid, and many of these are children. That
number would be even higher if we offered obstetrics. The
balance may or may not have health insurance. We don't care.
Everyone is seen. Many of our patients do have good health
insurance and could choose almost any hospital in Baton Rouge.
However, they come to us. It is the trust factor that I
mentioned earlier.
We have a facility designed to address emergencies that may
arise in the course of patient care or to stabilize patients
who come to our hospital, but need medical services that we do
not provide. We maintain a transfer arrangement with another
hospital and the local EMS personnel handle these transfers to
insure that the patient is provided the highest level of safety
possible while being moved from one hospital to another. In the
three years we have been open, we have not had to transfer an
admitted patient because of an emergency that was beyond our
capacity to address. Our nurses are ACLS certified, one of many
steps we take to maintain high quality at our facility.
One of the great frustrations we experienced before
building this hospital was the fact that we could not provide
the kind of medical and surgical care that we thought our
patients needed. All too often, minority patients have multiple
medical problems. In addition to needing a hip or knee
replacement or repair, they are also obese, diabetic and have
cardiovascular complications. Too many surgeons and too many
hospitals do not want to treat these patients, so they are told
that they are not appropriate for surgery and sent home, where
they deteriorate further. We knew that we could help these
patients with an organized approach that addressed their
medical complexities so that they could become good candidates
for surgery.
Since building our hospital, we have been able to reverse
this situation. We have established a close knit group of
physicians from many disciplines who work with us to help our
patients improve their overall health status. For example, I
often see patients in my office who need orthopedic surgery,
perhaps knee or hip replacement because of a lifetime of hard
work standing in a serving line at a cafeteria. The patient is
also overweight, hypertensive and has uncontrolled diabetes.
Like it or not, this is the reality of much minority medicine.
I know that this patient is not a good candidate for
surgery at this time, but instead of sending him or her away, I
develop a plan to improve their health status so that they can
eventually get the orthopedic procedure they need. Through this
network of health care providers I mentioned, I can get the
diabetes under control, get the hypertension managed properly,
and with good nutritional counseling, put the patient on the
path to a healthier diet and healthier weight. When this has
been done, I can then operate on the patient safely and with a
good outcome. This takes time and costs money, but the end
result for the patient is certainly worth the effort. In an
effort to be as economical as possible, we do not admit these
patients for weeks while addressing their medical complexities.
This is the most expensive way to meet the patient's needs and
exposes them to needless risk of infection or other
complication like blood clots from extended hospitalization. To
the greatest extent possible, my colleagues and I work to keep
these patients out of the hospital, until the day comes for
their surgery.
We do not cherry pick our patients, as has been suggested
of physician owned hospitals. We work to improve the health of
our patients to prepare them to be good candidates for surgery.
Are my patients healthier than some in the community hospital?
Absolutely, and it is because my colleagues and I have worked
hard to get them to that point.
Even if we cannot achieve the health goals for our
patients, we will still provide care. I frequently operate on
ASA level 4 patients, the most complex cases, at our physician
owned hospital. Because of the skill of our staff, we are able
to achieve good outcomes.
We built our hospital to address the health problems of
Baton Rouge's African American population some of which were
not being met at other facilities. In some cases, there is
simply the lack of trust this population has with the medical
establishment. Other cultural issues play a role, as well.
Certainly, if we could train more African American physicians,
this would help overcome at least part of this problem. I am
sure that among Hispanic and Native American populations
similar problems of trust and culture exist that could in part
be addressed if we trained more physicians and other health
providers from those groups. However, as we all know, the rates
of entry into the physician ranks by these populations are very
low and have remained so for many years. I know that H.R. 3014
proposes ways to deal with these shortages. That may be one of
the most important parts of this legislation.
However, health disparities are not just a function of race
or ethnic background. Economics plays an important role as
well. That is why we accept all patients regardless of ability
to pay. I am proud to say that we don't use a collection agency
to harass those individuals who can't pay their bills. I
believe that even with the number of uninsured people in this
country, if all hospitals worked together to address these
economic hardships financial barriers to care would begin to
fall across the country.
Access to health care can be limited by distance from
facilities. In Louisiana, we have parishes that have few, if
any, hospitals. Ever since Katrina, few people seem to want to
build hospitals in many of those areas. That is why I drive 90
miles to New Iberia to provide care. I also work in a parish
largely populated by low income whites, whose poverty prevents
them from getting the medical care they need. My colleagues at
our hospital perform similar outreach, travelling to outlying
areas to bring modern medicine to areas where this is in short
supply. Our hospital operates satellite clinics to extend our
reach to other areas where there is a need for our services.
My fellow physician investors built the Surgical Hospital
to improve access to care for African Americans who were not
receiving what they needed. Our role in the community and
surrounding areas has expanded and will continue to do so. I
can assure the Subcommittee, however, that if we had not been
able to build this hospital we never would have accomplished
what we have.
As this Subcommittee knows, access to medical services also
depends on the availability of facilities where that care can
be provided. Health disparities increased in Louisiana after
Hurricane Katrina because many hospitals were damaged or
destroyed. Rebuilding our capacity has not been easy especially
if physicians are involved in the effort. For example, St.
Bernard Parish was heavily damaged by Katrina and remains in a
very poor state. The two hospitals were destroyed and have not
been replaced. Local physicians wanted to build a hospital with
the support of a management company. However, other hospitals
outside of the Parish objected. That pressure, combined with
the uncertainty created by the debate over physician ownership
in Congress, ultimately caused the physicians to abandon the
effort. There is still no hospital in the Parish. It seems
clear that health disparities are not only related to poverty
or race, but also to community hospital greed and national
political activity. For those members of Congress who are
actively opposing physician ownership of hospitals like ours, I
don't know who you think you are helping. Certainly not the
residents of St. Bernard Parish who must travel long distances
to get hospital care.
Greater Baton Rouge Surgical Hospital is not alone among
physician owned hospitals in trying to reduce disparities in
health care in this country. Doctors Hospital at Renaissance in
McAllen, TX, serves a greatly underserved Hispanic population.
Most of the physician owners are also Hispanic, which helps
reduce the cultural and language barriers that can prevent
people from seeking and receiving timely medical care. St.
Joseph's Hospital in inner city Houston, serves underserved
African Americans and Hispanics. Local physicians, working with
a corporate partner, kept the hospital open so these people
could have convenient access to care. A similar effort is
underway at another Houston hospital, with physician leadership
and investment.
In Honolulu, Asian physicians have purchased two hospitals
that were going to close. Their effort will mean that the local
Hawaiian and Asian populations will continue to have easily
accessible, culturally appropriate health care.
Local physicians worked with the town of Troy, Alabama, to
rescue the only hospital in the town. Their willingness to risk
their own capital was the difference between success and
failure.
The Kansas Medical Society works through county medical
societies to try to get medical services to people who are
uninsured. Physician owned hospitals, including the best
orthopedic facility in the state, are teaming with the county
societies to make their services available to these underserved
individuals.
Native Americans are among the most poorly served patients
in our nation. Poverty, cultural issues, geographically remote
reservations and a myriad of health problems combine to create
one of the most difficult health situations in this country. An
over extended Indian Health Service cannot meet all of these
needs. However, physician owned hospitals particularly in
Western states like Colorado, Montana, and South Dakota provide
important services to all ages at reservations in several
states.
The many programs outlined in H.R. 3014 are just one
measure of the immensity of the health disparities problem in
this Nation. As physicians, we try to reduce them one patient
at a time. However, I can assure this subcommittee that my
colleagues and I could not accomplish what we do if we had not
built our hospital in Baton Rouge. The success of our facility
for patients, and the success of other physician owned
hospitals across the country, should be applauded and
encouraged. Any step, however small, that reduces health
disparities and improves care for patients should be nurtured.
Instead, I see too many Members of Congress apparently
determined to stop what my colleagues and I have been able to
do, by outlawing physician ownership of hospitals. I just don't
understand it. I invite you to come to my part of Baton Rouge.
You will quickly understand why health care innovation is so
essential if we are to improve health outcomes in this
community and why building our hospital was a turning point in
improving care for African Americans in our area.
In conclusion, Mr. Chairman, thank you for having this
hearing and shining light on a major problem in our health care
system. Thanks to all of the Members of the Subcommittee for
their interest in learning more and working on solutions. Those
of us in the trenches trying to battle these barriers ask only
that you and your colleagues work on a bipartisan basis to
provide some solutions involving the entire healthcare
community. Our experience, and the experience of others, shows
that there is a role that the physician owned hospital can play
in this effort. I hope you recognize this as well and will
silence our critics whose primary aim in life seems to be their
financial health and control of the system, not the health of
their patients. If H.R. 3014 is passed by Congress, I urge you
to make sure that physician owned facilities can participate
equally with other hospitals.
I would be happy to try to answer any questions the
Subcommittee members may have.
----------
Mr. Pallone. Thank you very much. I hate to do that, but we
have a large panel. And next is Ms. Murguia, who is from La
Raza.
STATEMENT OF JANET MURGUIA, J.D., PRESIDENT AND CEO, NATIONAL
COUNCIL OF LA RAZA
Ms. Murguia. Sure. Thank you. Good afternoon, Mr. Chairman
and thank you for the opportunity to testify today. Restoring
equity to our healthcare system is a major priority for NCLR
and for the Latino community and we do appreciate being part of
this important discussion. I would like to, specifically, thank
Congresswoman Hilda Solis and her colleagues in the Tri-caucus
for their leadership on this vital issue. This is an important
bill. She has been a great champion on these issues. It has
been nearly a decade since the last health disparities
legislation was enacted. That legislation had a significant
impact on improving research, investigating how racial and
ethnic minorities fair within the healthcare system. As a
result, it is clear that Latinos and other racial and ethnic
minorities continue to face significant challenges in accessing
high quality care.
According to the Agency for Healthcare Research and
Quality, AHRQ, healthcare may be growing worse for Latinos.
Since AHRQ started regular collection of health disparities
data in 2002, the gap in healthcare has been seen to grow wider
between Hispanic and white individuals. Some key reasons that
Latinos continue to face disparities include the fact that we
are still the Nation's highest level of uninsured. More than
one in three, or 34.1 percent of Latinos is uninsured. Latinos
are more likely than other Americans to participate in the
workforce, but less likely to have health insurance.
Furthermore, entire sectors of the Latino population have
been cut off from important safety net programs. Legal
immigrants, in particular, are barred from Medicaid and CHIP
for their first 5 years of legal residency. Barriers to
linguistically appropriate care, Latinos who are still learning
English face considerable difficulty in accessing information,
enrolling in healthcare programs and receiving the treatment
that they need. As a result, these individuals are more likely,
than other Americans, to experience adverse outcomes if they
manage to get care at all.
We also see discrimination in healthcare settings. In 2004
NCLR commissioned a testing study evaluating treatment of
Latinos in the greater Washington D.C. area and the benefit
system and found evidence that discrimination was taking place
on the basis of national origin. In the study, NCLR found that
80 percent of Latinos in the test experienced at least one
serious hurdle in obtaining benefits.
The lack of healthcare providers is still another important
factor that remains. Latinos are far underrepresented in the
health workforce. This in turn undercuts access to the quality
of care. Given these trends, H.R. 3014 is a desperately needed
piece of legislation. Using many of the recommendations of the
Institute of Medicines, Unequal Treatment Report, the
Congressional Tri-caucus has crafted a comprehensive set of
changes that will improve our healthcare system. We know that
this bill will restore access to critical programs for some
legal residing immigrant children and pregnant women and seal
our hopes that this strong start will be expanded on as
intended by the bills sponsors, covering all lawfully residing
children and pregnant women.
H.R. 3014 encourages effective communication in healthcare
settings, especially by facilitating language access and
culturally linguistic appropriate care. The legislation
increases accountability in healthcare by ensuring that the
Office of Civil Rights, under HHS, has the authority to pursue
full enforcement of civil rights law for persons who are
discriminated against in healthcare settings. And the bill
promotes diversity in healthcare workforce by expanding
programs to increase the number of health professionals form
diverse populations, and by expanding cultural competence
training. It supports community based approaches to healthcare
and service delivery by helping to bring effective health
promotion and health service programs to scale.
This legislation also increases resources for community
health centers and other community based programs which are
often the center of care for the medically underserved. We
strongly, on behalf of the Latino community and NCLR, encourage
votes supporting this legislation and we ask the Committee to
ensure its swift consideration in the coming months. We look
forward to supporting and working with you on the Committee.
Thank you very much.
[The prepared statement of Ms. Murguia follows:]
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Mr. Pallone. Thank you. Mr. Lesley.
STATEMENT OF BRUCE LESLEY, PRESIDENT, FIRST FOCUS
Mr. Lesley. Thank you. Good afternoon, Chairman Pallone,
Congresswoman Solis, and staff of the House Subcommittee. I am
Bruce Lesley, President of First Focus, a bipartisan children's
advocacy organization dedicated to making children and families
a priority in Federal policy and budget decisions. I appreciate
the opportunity to testify today in support of the Health
Equity and Accountability Act and thank Congresswoman Solis and
Christensen for their leadership on this legislation aimed at
reducing health disparities by improving access to healthcare
research, and education of the diseases and illnesses that are
having a disproportionate impact on minorities.
There is much that can and should be done to improve
healthcare delivery systems in this country in order to
better--to ensure better quality and appropriate care for all
people, regardless of their race, ethnicity, cultural heritage
or economic status. I am grateful that you are exploring these
issues today. The Health Equity and Accountability Act is an
important and timely proposal and it is our hope that passage
of the bill will put our Nation on the critical path toward
reducing, eliminating disparities for all Americans, including
children across the healthcare spectrum. We should strive for
nothing less.
Unfortunately, as First Focus Advisory Board member and
pediatric expert Dr. Glenn Flores has noted, very little
attention to health disparities has been directed at children.
According to Dr. Flores, in a recent report on disparities by
the Agency for Healthcare Research and Quality, there were more
than three times as many disparity measures for adults as there
were for children and only 15 percent of measures were child
specific, and in the Institute of Medicine's comprehensive
health disparities monograph, only 5 percent of the studies
addressed disparities in children, at all.
However, we do know that minority children typically fare
far worse than white children across the spectrum of health
outcomes. From infant mortality, obesity, and dental care to
asthma, diabetes and environmental illnesses, which is an issue
also Congresswoman Solis has legislation on. Minority children
have higher rates of disease and more limited access to care
than the non-minority population. As Dr. Flores adds, minority
children in American often face a triple threat of greater
risks of suboptimal medical and oral health status, impaired
access to medical and dental care and lower receipt of
prescription medications and essential medical and dental
services.
The statistics are startling. For example, we know that
elevated blood levels are far more common in African American
children, as opposed to white children, four times more, so.
The incidence of Type 2 diabetes is running faster among the
American Indian and Alaska Native children and young adults
than any other ethnic population and is 2.6 times the national
average. And Latino preschoolers, the fastest growing
population of children in the United States, experience 2.5
times more tooth decay than white children. These are just
examples of many health disparities for children that are
included in my testimony.
While there are many factors that contribute to these grim
statistics, chief among them is that minority children face
significantly higher rates of uninsurance when compared with
white children. Nearly two-thirds, or 64 percent, of the 9
million children in the United States who area uninsured belong
to a racial or ethnic minority. This morning there was also
testimony about rural Americans and the fact is rural
Americans, rural children, are disproportionately uninsured as
well.
The bottom line is that we are failing our Nation's
children, our next generation of leaders, by denying them the
opportunity to fulfill their promise due to the lack of a
healthy start in life. The disparities in access care, coverage
treatment, and outcomes are abysmal and unacceptable. They are
highlighted by the fact that on the average day 76 babies die
before reaching their first birthday. If we did nothing else,
as a society, we cannot let that figure stand. For this reason
I would like to highlight the need to pass the Healthy Start
Reauthorization bill by Congressman Towns and Upton, bipartisan
legislation, as infant mortality is on the rise again, and it
is also an issue of health disparities.
For all these reasons, the Health Equity and Accountability
Act must be advanced as quickly as possible. While we
appreciate all the efforts by Congress in recent years to enact
legislation to address health disparities, these issues have
become urgent ones and we cannot let more time pass without
taking critical steps to address them.
We applaud the provisions of the bill that would, one, give
States the option to provide coverage under SCHIP and Medicaid
for legal immigrant children and pregnant women. This is
legislation by Republican Congressman Diaz-Balart that is also
included in the bill, provide grants to support community
health worker programs, which improve enrollment strategies
among minority communities including the use of promotoras to
guide families through the enrollment process. That is in the
bill, but also a freestanding piece of legislation by
Congresswoman Solis. Ensure the availability of culturally and
linguistically appropriate healthcare services, require data
collection and analysis on disparities, provide grants to
increase the number of minority health professions, Support
training programs for providers who treat an increasing diverse
patient population and improve research and education on
diseases that are found to be more prevalent in minority
communities. Thank you for the opportunity to provide this
testimony and welcome any questions.
[The prepared statement of Mr. Lesley follows:]
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Mr. Pallone. Thank you. Ms. Yang, or Ms. Jang, I am sorry.
STATEMENT OF DEEANA JANG, J.D., POLICY DIRECTOR, ASIAN AND
PACIFIC ISLANDER AMERICAN HEALTH FORUM
Ms. Jang. Thank you, Chairman Pallone and Committee staff
for inviting me to testify on disparities in health and
healthcare. I also want to thank Congresswoman Solis for your
leadership, along with members of the Congressional Tri-caucus
in taking a comprehensive approach to achieving health equity
through introduction of H.R. 3014. My name is Deeana Jang and I
am the policy director for the Asian and Pacific Islander
American Health Forum, a national advocacy organization
dedicated to improving the health and well being of Asian
Americans and Pacific Islanders.
Contrary to the popular perception that Asian Americans are
successful, wealthy, and healthy, Asian Americans and Pacific
Islanders do experience disparities in health coverage, access
to care, quality of care and health outcomes and disease
prevalence. Asian American and Pacific Islander communities are
not homogenous. There is a lack of data on specific ethnic
subgroups that mask disparities that these communities
experience. For example, 17 percent of Asian Americans and 24
percent of Pacific Islanders are uninsured compared to 12
percent of non-Hispanic whites, but the rates of uninsurance
for some subgroups are even greater. Factors such as language,
cultural barriers, and citizenship requirements prevent many
Asian Americans and Pacific Islanders from accessing quality
care. H.R. 3014 contains many provisions that will improve
access to health coverage, access to healthcare services,
improve the quality of care and increase investments in
community-based approaches to achieve health equity.
I want to focus on just a few of the provisions that
address these issues. 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. We
support H.R. 3014's provisions to develop standards for
collection and reporting of data on race, ethnicity and primary
language and require its collection by all HHS programs using,
at minimum, the 1997 OMB revised standards and, when possible,
disaggregating by ethnic subgroups.
More needs to be done to improve data collection on smaller
populations, including Asian Americans and Pacific Islanders.
On the National and State level, data on Asian Americans and
Pacific Islander health are either reported as other or
reported as one group, which again masks those disparities. We
support policies that improve the collection, analysis, and
reporting of data on Asian Americans and Pacific Islanders,
including translation of survey instruments and use of
bilingual interviewers, over sampling and pooling data on
smaller populations, increasing funding for community based
participatory research and providing resources for more data
collection at regional, State, and community levels.
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
adverse outcomes. More than a third of Asian Americans and 12
percent of Pacific Islanders speak English less than very well.
More funding for language assistance, technical assistance for
providers and more enforcement of civil rights laws are
necessary components to ensuring that limited English
proficient persons can access quality healthcare. Although
States can get Federal matching funds from Medicaid and SCHIP
for the cost of language services, only about a dozen States
have taken advantage of this option. Providing 100 percent
funding through H.R. 3014 will certainly provide a greater
incentive for States to reimburse providers for these costs.
Barriers to participation in Federal Healthcare programs
must be removed for immigrants and other non-citizens,
including Pacific Islanders. Over 40 percent of Southeast
Asians and about half of all Pacific Islanders are poor, or
near poor and have high rates of uninsurance. Removing barriers
and expanding eligibility for public programs will go far to
addressing coverage for these populations. Thirty two percent
of Asian Americans and 22 percent of Pacific Islanders are
noncitizens. Thirteen percent of Asian Americans are
noncitizens residing in the United States for less than 6
years. Since 1996, legal immigrants and low income families
have been barred from receiving Medicaid or SCHIP during their
first 5 years in the U.S.
Furthermore, citizens of the Republic of the Marshall
Islands, the Federated States of Micronesia and the Republic of
Palau are ineligible for public programs, as well, even though
they are allowed to work and travel to the U.S. Many of these
Pacific Islanders have health issues for which they are unable
to access care. We support the provisions in H.R. 3014 to allow
states to cover lawfully residing immigrant children and
pregnant women. We urge the Committee to include all lawfully
residing immigrant children and pregnant women, including
permanent residents and qualified battered women who are
ineligible because of the 5 year bar. H.R. 3014 would also
provide eligibility for public health programs for citizens of
the Republic of the Marshall Islands, the Federated States of
Micronesia, and Palau.
We have additional comments about other sections of H.R.
3014, including promoting a diverse and culturally competent
workforce, supporting community-driven approaches to achieve
health equity and having accountability on the Federal
Government level. These are included in our written testimony.
We look forward to working with the Committee to move this
critical piece of legislation as soon as possible. Thank you
very much.
[The prepared statement of Ms. Jang follows:]
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Mr. Pallone. Thank you and we will now have questions from
the panel and start with myself, and I wanted to start with Dr.
Lavizzo-Mourey. Some would try to downplay the importance of
addressing racial and ethnic disparities by changing the debate
to focus on income and education. And while income and
education do matter in terms of health outcomes, isn't it true
that disparities continue to exist even after looking at income
and education?
Dr. Lavizzo-Mourey. That is absolutely right, Mr. Chairman.
The Institute of Medicine Report demonstrated that even
controlling for race, for income, and education, disparities
continue to exist. Now, I will give you one specific example:
the condition of low birth weight among African American women,
the children of African American women. Even controlling for
college education, we still see a marked disparity in the
incidence of low birth weight, so it is important to not only
focus on education and socioeconomic status, but also on race
and ethnicity.
Mr. Pallone. And the problem I see is if you don't do that
and you don't focus on race and ethnicity, then you wouldn't
collect the data. In other words, the importance of improving
and collecting data on race and ethnicity would be thrown
aside. So, if you want to comment on that.
Dr. Lavizzo-Mourey. One of the critical things to actually
making improvements is knowing at a local level what
disparities exist. So, for example, we know with amputation
rates there is a four fold difference between blacks and
whites, but when you look at specific States, the variation is
sometimes larger than that and sometimes smaller than that. We
give specific examples in our written testimony. Without
collecting that data by race and ethnicity we aren't going to
know on a State or regional or local level how to focus
resources to really address the problem.
Mr. Pallone. OK. Now, let me issue another question about
the uninsured, and maybe I will ask Bruce Lesley to join in on
this as well. A number of studies have shown that minorities
are more likely than whites to be uninsured and lack of
insurance coverage impedes access to healthcare which causes
people to forego needed care and leads to worse outcomes and
greater costs in the long run. Can we really address
disparities without making sure that everyone is covered? In
other words, how important is that in this whole issue of
addressing disparities?
Dr. Lavizzo-Mourey. It is critical. We funded a number of
studies that show that there are devastating consequences, both
physical and economic, of not having coverage and access, but
it is not the whole story. In addition, we know that in order
to actually reduce the disparities we have to focus on issues
of quality that are addressed in this bill, so one is not
sufficient, you need both.
Mr. Pallone. Now, if I use an example with the SCHIP
program, which you know we have been trying to push throughout
this Congress, in this subcommittee to expand it, and I know
you have been a strong supporter of SCHIP and Medicaid and
expansion. What do you think? Would an expanded SCHIP or more
robust Medicaid make significant strides in reducing health
disparities, in your opinion?
Dr. Lavizzo-Mourey. We absolutely know that when children
have access to high quality care, they have better health
outcomes. You can look at vaccination rates. You can look at
other specific conditions, so yes we know that having access to
care will make a dramatic difference.
Mr. Pallone. Did you want to address that too, Mr. Lesley?
Mr. Lesley. Yes, absolutely. There has been a number--
Mr. Pallone. And maybe beyond the health insurance, what
else do you suggest we do?
Mr. Lesley. Sure. There is a number of studies that have
shown--for example, there was a recent study on SCHIP in New
York and in New Jersey and then also in California on the
expansions of SCHIP and the importance of how they have
dramatically reduced health disparities. It was the, in some
instances, actually eliminated disparities on some indicators.
I also think that what is so great about the legislation is
that you are also including things like the community health
workers provisions and other provisions that are, as part of
the legislation, that also have shown and demonstrated dramatic
reductions in disparities.
Mr. Pallone. And then the last thing I was going to ask is
about a Federal solution, and you know this is not only
important for this year, but next Congress. I mean, do you
think that you need a Federal solution for disparities, because
some would argue that you could address this more on a local
level or a state level. What do you think about the need for a
Federal approach?
Mr. Lesley. Well, I think a Federal approach is critical
because what you see is the--with all the differentials, you
are seeing closing of the gap in areas where we are having
expansions of coverage and not in other areas, and so the gains
that were made in California due to the economic problems--in
California there is actually regressing on some of their
coverage and we are beginning to see signs of increased
disparities and problems for children, particularly, that we
know of in SCHIP, for example, and so without a Federal
solution and really providing that overlay, for example, the
areas of the southwest and the south will continue to fall
behind. And you can look at the U.S.-Mexico border, for
example, they have the highest rates of uninsured in the
country and huge health disparity issues for Hispanic
communities along the border and Native American communities
and unless we do something nationally and really raise the
level for all children those disparities will continue.
Mr. Pallone. Well, my time is up. I agree with you, but
beyond that, I think particularly when you talk about Native
Americans, if you don't have the Federal approach, it is going
to----
Mr. Lesley. Right.
Mr. Pallone. Unfortunately, a lot of times the States and
the locals really don't pay much attention at all to them. I am
sure that is true for others, but I know it is true for them.
Thank you. Ms. Solis.
Ms. Solis. Thank you, Mr. Chairman, and I want to applaud
the testimony of some of our witnesses here and want to thank
you for your interest. This is a work in progress as you can
tell, and I am very excited about the fact that some of the
things that you all have discussed have been around for awhile.
The problem is, we haven't seen sufficient funding. We didn't
really get a whole lot into what NIH and the Office of Civil
Rights can do, but I would like to hear, maybe from Dr.
Lavizzo-Mourey to tell me a little bit about what you think we
ought to be doing in terms of helping to build up research and
the capacity to have professionals that we can attract into
this field and where do we need to place them?
Dr. Lavizzo-Mourey. We have invested, for about 30 years,
in trying to increase the pipeline of healthcare professionals,
physicians, nurses, health providers of all kinds, but also
people working in public health, and I think there are some
critical things that we have learned, and one is that the
pipeline needs to start early. It has to involve not only the
college years, but the pre-college years and needs to extend
well beyond the terminal degree of professional school to
ensure that people have the skills that they need at the
specialty level and very importantly, particularly for nurses,
that they are encouraged to take faculty positions that they
can then inform and educate the next generation. So the main
point I want to make is that it is a long pipeline and we have
to invest at all levels or it will only be as strong as the
weakest link there.
Ms. Solis. Would you say that over the last 7 years we have
done a sufficient job in funding some of these, say, particular
positions for loan repayment? We talked a little bit about that
earlier, on the first panel.
Dr. Lavizzo-Mourey. I am not going to able to comment
specifically about the funding of those.
Ms. Solis. Would anyone on the panel want to address that?
Ms. Murguia. Well, I would just add that I think that we
haven't seen enough funding. There are, I think, opportunities
here to reach out into these communities and get to these
individuals at earlier stages. There are other approaches too
and I think as a community based--we represent a number of
community based organizations that do work in health promotion
and in health clinics, but we--one of our programs, which is
recognized by the Department of Labor because we have a health
career pathways, and what we have started is a lot of
individuals who had been health promoters working as either
interpreters or going in and accompanying some of these
patients, we have been able to find ways to create a pathway
for them to then become nurses aides or then to go on and to
become physicians' assistants or then to become nurses, and we
are working with community colleges. But there are programs, if
we are collaborating, where we can see further development of
health professions in a community-based way.
Ms. Solis. And, Mr. Lesley, you talked a little bit about
community workers, or the promotoras program and that was a
part, actually, an area that we tried to get in the CHAMP Act
too, to increase outreach and just make sure that we get a hold
of these populations that are not receiving care. In your
testimony, you didn't get a chance to touch on it, but I wanted
to go back to citizenship documentation and some of the
barriers that really creates for people who are legally here,
who are eligible for services and the barriers that they are
confronting, given a misguided, in my opinion, regulation that
is actually keeping U.S. citizens from healthcare. Could you
elaborate on that?
Mr. Lesley. Yes, absolutely. There have been a number of
studies that actually have shown that the--at a high cost.
There was actually a story last week in a Kansas newspaper that
talked about that they have now done the analysis of the
citizenship documentation provision, it has cost them over a
million dollars to implement. They have prevented one person
from getting coverage that shouldn't have gotten coverage, but
thousands of--20,000 people who should have gotten coverage
have been denied due to various documentation problems. So, at
an enormous cost, really haven't achieved the goal of the
program, but have been, on the flip side, actually dumped
people from coverage and so it is one of those things that we
certainly support getting rid of that provision or modifying it
substantially as it was included in the CHAMP act.
Ms. Solis. And why is it important, Ms. Jang, to provide
legal immigrant healthcare coverage to women and children?
Ms. Jang. Well, we know having early prenatal care really
helps in terms of outcomes for both the mother and the child,
so it is very important. It saves money. For every dollar spent
on prenatal care, you save $3 in complications later on, so it
is very important to get children and pregnant mothers the care
that they need, when they need it.
Ms. Solis. And Dr. Knatt, you talked about your experience
there in Louisiana. Some of us were able to go out and visit
some of the makeshift clinics and actually saw the hospital in
New Orleans, Louisiana that was devastated. And I understand
that it still has not come back the way it should be, and there
are obviously healthcare disparities that exist in and around
that community and I know you didn't get to say your entire
statement, but are you in support of this type of legislation?
Dr. Knatt. Oh, absolutely. I think that healthcare
disparities are quite prominent in the U.S., particularly in
our area and what we have done has helped to almost eliminate
it.
Ms. Solis. Do you think the Federal government should be
involved in this? I mean, because you are obviously coming from
the private practice here, but is that something that you think
would be welcomed?
Dr. Knatt. Yes, I think it is something that should be
addressed at the national level. They mentioned earlier that
the workforce needs to increase, but I think it needs to go
beyond that. We need to increase the workforce. We also need to
protect that workforce without giving them any unfair
favoritism. There is a lot of pressure when minority physicians
go into a community. I think that the percentage of physicians
should reflect the percentage of the population in the United
States.
Ms. Solis. And is my time up?
Mr. Pallone. Your time is up, but I am not worried about
it, so just keep going.
Ms. Solis. I just wanted to ask Dr. Akhter if he could,
also, just elaborate--he talked about the African-American
physicians and I know a group out where I live in Los Angeles,
a Hispanic and Latino medical group that provides sufficient
services. Their main problem or question to me is always lack
of adequate reimbursement and, of course, keeping and competing
with other neighboring for-profit hospitals. Can you elaborate
on that? What I find really discouraging is that many of our
Hispanic doctors who want to stay in east Los Angeles or other
very hard pressed areas, financially can't and they are not
given the kind of encouragement by other entities to give them
the capital they need to continue on the private sector. So, if
you could elaborate a little bit on that and explain that to
us?
Dr. Akhter. I think the fundamental problem is lack of
health insurance. That is really at the bottom of this. When
you see one out of every four African American are uninsured,
one in three Hispanic uninsured, then you can start to see that
in those communities where our minorities live, there are many
more--proportionately many more people who are uninsured. So,
it was very difficult for a provider to go into that community
and make it as a business. If every third person walking in is
going to have no insurance to pay, you have difficulty, and
then reimbursement rates are so low. So, we really have great
disincentive for people to go and practice in minority
communities and that is something that we really need to change
and that needs to be changed at the National level. Remember,
this is not an African American problem, Hispanic problem,
Asian problem. It is an American problem. It is a national
issue and needs to be addressed at the national level.
Ms. Solis. And I would concur with you. During our first
panel, Congressman Moran talked about the inequities that exist
in rural America. I agree with his statement wholeheartedly and
know that there are economic issues, socioeconomic, literacy
issues that just abound. They affect those that are least able
to defend themselves, so I understand that that is something
that we have to work on. As we work through this legislation we
can build more support from our colleagues in the rural area.
Yes?
Mr. Lesley. Congresswoman Solis, I think that is a very
important issue and one of the things I think that is a great
step that the legislation provides and, for example, CHAMP
provided last year is the idea that, for example, today you are
all voting on the Medicare physician payment issue. Lots of
issues have gone on. I think we did a Congressional Quarterly
search on quality issues and Medicare and you get hundreds of
hits. One of the important steps that reauthorization of SCHIP
will do is address--start to deal with these issues of quality
and payment and--that really have been, have not happened on
the SCHIP Medicaid side to the extent that they have been going
on in Medicare, and the information technology. And what that
has meant is that, really, kids and families, low income
families have been left behind in that discussion.
Mr. Pallone. Thank you, and thank you Congresswoman Solis,
and thank all of you really. I know this is a very important
issue and I think that you have done a very thorough job today
of analyzing what we face and the significance of this bill. We
have got a lot more work to do, but this is certainly a good
beginning. Let me remind you that we may submit additional
questions to be answered in writing. The clerk should get those
to you--well, the members will submit it to the clerk within
the next 10 days and then soon after that we would send those
written questions to you, but if you could respond to those in
writing, we certainly appreciate it, and I also want you to
know that as far as this subcommittee and myself and Ms. Solis
is concerned we do intend to try to address the issues that you
have brought up here today. We are not just going to hear them
today and say that is the end of it, so thank you again and
without objection--oh, I am sorry. I do have one more thing--
bit of business here. We have a number of items for the record
so I am going to ask unanimous consent that the following
materials be included in the record. First is the Tri-caucus
letter of support for a hearing on H.R. 3014. Second is local,
State and National organizations letters of support for the
hearing. Third is testimony from Representative Donna
Christensen, then we have a statement from Representative Mike
Honda, a statement from Kaiser Permanente Medical Care Program,
an AdMe Tech letter to myself and Ranking Member Deal on the
issue of prostate cancer, my own opening statement since I
wasn't here in the beginning and various newspaper articles, a
report and a statement from Representative Ed Towns. So,
without objection, so ordered and without objection this
meeting of the subcommittee is adjourned. Thank you.
[Whereupon, at 1:43 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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Prepared Statement of Hon. Mike Honda
Thank you Chairman Pallone and Ranking Member Deal for the
opportunity to comment on this morning's important hearing on
H.R. 3014, the Health Equity and Accountability Act. As
Chairman of CAPAC, I have the honor to speak on behalf of the
Congressional Asian Pacific American Caucus on the health
concerns and needs of the greater Asian American and Pacific
Islander community.
Asian American and Pacific Islanders (AAPIA) are one of the
fastest growing populations in our country today. Over the last
18 years, the AAPI community has more than doubled from seven
million to over 15 million individuals and this is a community
represented in every Congressional District across the country.
My home county of Santa Clara County is nearly 30% Asian
American and Pacific Islander, and as many as 12.8 percent of
the 36 million residents of the State of California today are
Asian American and Pacific Islander.
Nearly every American faces challenges today to accessing
quality and affordable healthcare, but these challenges are
unequally faced across the broader spectrum of our economically
and ethnically diverse country. Asian American and Pacific
Islanders, like Latino Americans and African Americans,
struggle with overcoming the additional obstacle of healthcare
disparities. The common needs of our various minority
communities led to the introduction of health disparities
legislation 6 years ago. We have worked hard as a tri-caucus to
keep the issue of health disparities at the forefront of the
health care debate.
Unlike other minority communities, however, the rapid
growth and wide diversity in language and culture within the
greater Asian American and Pacific Islander community presents
its own unique healthcare challenges. Asian American and
Pacific Islanders encompass 49 ethnicities and over 100
individual and distinct languages and cultures making several
provisions contained by H.R. 3014 critically important to
improving healthcare for AAPIs.
H.R. 3014 is the product of collaboration between the
Congressional Black Caucus, the Congressional Hispanic Caucus,
and the Congressional Asian Pacific American Caucus, and
comprehensively addresses from a public policy perspective the
pressing issues faced by communities of color in our country.
This bill, which has now been introduced in three consecutive
Congresses, demands our attention and deserves this
subcommittee's consideration. Its provisions have been
scrutinized by the medical, health professional and academic
communities and are based on Tri-Caucus facilitation with the
advocacy community.
I appreciate the extraordinary leadership and work of
Congresswoman Donna Christensen and Congresswoman Hilda Solis.
It has been wonderful to work with them to as we move forward
as a Congress to develop and pursue public policy that will
reduce and eliminate healthcare disparities. This hearing is
another, long-awaited step to achieving our goal of eliminating
health disparities. Although the AAPI community is impacted by
virtually every aspect of the bill, I want to highlight the
data collection title of the bill and also comment about
broader access challenges.
Today, the Federal Government lacks complete, adequate, and
up-to-date medical data for minorities, but because of its
diversity the data gap for the AAPI community is more glaring
and consequential. Right now, if you search for diabetes
information on the Centers for Disease Control and Prevention
website, you will only find data categorized for ``Black,
White, and Hispanic or Non-White.'' 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.''
Although this one very specific example it nevertheless
aptly illustrates the information gap for minorities,
particularly for the AAPI community. We as a Congress simply
cannot address or rightly aim to correct the health challenges
facing our citizens if we do not even know what they are or
have some authoritative, sound measure of the extent of impact
and contributing cause.
Equally disconcerting is the fact that is has now been over
a decade since the Office of Management and Budget (OMB)
established new standards for the collection of federal data on
race and ethnicity, yet their full adoption and implementation
by certain federal agencies remains outstanding. The Social
Security Administration (SSA), for example, has made no
revision to its Social Security Card application to take into
account the news standards. The OMB race and ethnicity-
developed categories are by no means burdensome to implement--
they simply establish the minimum categories of race as
American Indian/Alaska Native; Asian; Black or African-
American; Hispanic/Latino; Native Hawaiian/Pacific Islander,
and White. Without the use of these standards, inconsistency is
in place across our government and we as policy-makers struggle
to receive needed data and the work to make desired
comparisons, measure correlation, and analyze data is
compounded and made unreachable.
CAPAC believes that further disaggregation beyond the OMB
standards established ten years ago is warranted today to
accurately reflect the diversity of the AAPI community.
However, we know this step cannot logically be taken or fully
pursued into the spirit of the 1997 changes are adhered to by
our Federal Government. Therefore, compliance with the 1997
standards and additional collection of data on primary language
is a priority--H.R. 3014 requires such collection and
disaggregation. Such compliance and additional data collection
is imperative for tracking and eventually eliminating health
disparities in the AAPI community. The improper or insufficient
collection of data by the Social Security Administration leaves
a lasting impact on our ability to monitor the quality of care
and eliminates our ability to rely on what would otherwise be
invaluable indicators for effective administration of the
Medicare and Medicaid programs.
Apart from standards, compliance and consistency in
application are other data collection priorities. H.R. 3014
strengthens data collection and analysis by requiring that
racial and ethnic data be collected from the parent or legal
guardian of minors and reported to the Centers for Medicare and
Medicaid Services and other relevant agencies for proper
analysis.
Finally, I would like to underscore the critical importance
of cultural and linguistic competency in healthcare. This issue
is vital for the AAPI community. Roughly a third of Asian and
Pacific Islander Americans live in linguistic isolation; 70% of
Cambodians, 68% of Laotians, 61% of Vietnamese, 52% of Koreans,
51% of Chinese, 39% of Tongans, and 22% of Samoans are
classified as Limited English Proficient (LEP) and interaction
with healthcare providers and social service agencies is
hampered because of these language barriers. These barriers
have severe effects on healthcare access, such as patients'
ability to understand diagnoses, ability to understand
prescription directions, and likelihood to return for follow-up
and preventive care in the future. People have and will
continue to die as a result of misinformation or
mistranslation.
It is for these reasons, and for a host of others that will
be addressed by the experts testifying before you today, I urge
your attention to and focus on H.R. 3014. Health disparities
for Asian American and Pacific Islanders are very real; and
people are suffering everyday from these disparities. As we
move toward a model of universal coverage or universal care it
is important that we address these disparities now. Thank you
for the opportunity to comment on this important issue.
----------
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Prepared Statement of Hon. Frank Pallone
Good morning. Today the Subcommittee is meeting to review
H.R. 3014, the ``Health Equity and Accountability Act of
2007,'' introduced by my colleague, Ms. Solis. I would like to
thank you for all your work on this legislation. I would also
like to highlight the efforts of the TriCaucus Members and
thank all of them for their tireless work on this legislation.
This hearing is long overdue and I am pleased that we have the
opportunity today to address this very important topic.
Though we as a nation have made tremendous strides in
improving the health of all Americans, there remain significant
inequalities with respect to both access to health care and the
quality of care provided among different ethnic groups in this
country. As numerous reports have been published highlighting
these gaps in our health care system, it is clear that action
must be taken to address these inequalities.
For example, the mortality rate due to heart disease is
highest among African Americans; cancer deaths are increasing
at a faster rate among Asian Americans and Pacific Islanders
than any other racial or ethnic groups; and the rate of new
AIDS cases is three times higher among Hispanics than among
Caucasians. I, personally, am also very concerned about the
health disparities for American Indians and Alaskan Natives.
The mortality rate among Indian infants is 150 percent higher
than for Caucasian infants, and Indians are nearly three times
as likely to be diagnosed with diabetes. Depression is rampant
and suicide is two and a half times higher in this population
than the national average--in fact, suicide is the second
leading cause of death for Indian youth.
These disparities are not limited, however, to ethnic and
racial divides, but are consistently also found between
genders, geographic area, and among differing income groups.
The National Center for Health Statistic's recent report
highlights the longer life expectancy for women than for men.
There are significantly more access-to-care obstacles for rural
populations than there are for urban populations, and the 2002
Institute of Medicine report found that these disparities
persisted even when factors such as insurance coverage and
income level remained constant. Clearly, these disparities in
health services and care are an all encompassing challenge that
must be addressed.
Just recently, the Robert Wood Johnson Foundation--the
largest health care foundation in the country--announced a $300
million dollar commitment to close the gap in health care
disparities across ethnic, religious, and geographic lines.
This project will seek to answer crucial questions through data
collection in an attempt to better understand the causes of
regional health variations. Part of the funds will also be used
to pay for national experts who will help grantees tailor their
quality improvement plans to their specific communities.
Ultimately, this research will work to reduce disparities and
provide the groundwork for national health reform models.
While the work of this and other philanthropic
organizations is vital in our efforts to close the health
disparities gap, more can be done on a federal level as well.
With legislation such as the bill we are hearing about today,
we can gather more information to develop a multi-faceted
approach that will one day eliminate disparities in health.
The ``Health Equity and Accountability Act,'' H.R. 3014,
targets the underlying causes of the current health disparity
crisis, including racial, ethnic, gender, and rural
disparities. The bill would strengthen educational institutions
and reinforce efforts to ensure culturally sensitive health
care, such as overcoming language barriers. It would support
programs to address the shortage of health care providers
focusing specifically on those that address minority health
care providers. Finally, it would establish community-centric
initiatives to improve health care services and eliminate
health disparities among legal citizens.
I would like to take this opportunity to clarify a point I
know some in this room will try to raise. The intent of this
legislation is to close the health gap for individuals who are
legally present in this country. We actually used many of these
provisions in the CHAMP bill. During our work on the CHAMP Act
it came to our attention that we needed to clarify these
provisions and we made the necessary changes at that time. The
bill before us has not yet been clarified, but I do want to
point out again, the provision in question is not intended to
cover illegal immigrants but rather to provide legal pregnant
women and children access to health care. It is my hope that
the conversation this morning will focus on the goals of this
bill, which are to eliminate the underlying causes of health
care disparities. I hope that my colleagues on both sides of
the isle would respect that rather than turning this health
disparities hearing into a heated battle on immigration issues.
I would like to thank the witnesses for appearing before us
today to share their expertise. I look forward to your
testimony and your insight on how this legislation would
address some of the very prevalent health care disparities
problems this country faces today.
I would especially like to welcome Dr. Risa Lavizzo-Mourey
from the Robert Wood Johnson Foundation, which is located in my
district. Thank you for coming down from my home state of New
Jersey to testify. And Majority Whip Clyburn and Congressman
Moran, it is a pleasure to have you both join us as well. I now
recognize my colleague from Georgia, Mr. Deal, for 5 minutes
for his opening statement.
----------
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