[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

                              ----------                              
                                                                   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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