Transcript Slide 1

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Webinar will begin shortly.
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Dr. Terry Cline, PhD;
Commissioner, Oklahoma State
Department of Health
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Dr. Brian Smedley, PhD, Vice President and
Director, Health Policy Institute of the Joint
Center for Political and Economic Studies
Anna Whiting Sorrell, MPA, Director, Montana
Department of Public Health and Human Services
Jane Smilie, MPH, Administrator, Montana
Department of Public Health and Human
Services, Public Health and Safety Division
John Auerbach, MBA, Commissioner,
Massachusetts Department of Public Health
Challenges and Opportunities in
Advancing Health Equity:
Making the Economic Case
Brian D. Smedley, Ph.D.
Joint Center for Political and Economic Studies
www.jointcenter.org
The Economic Burden of Health
Inequalities in the United States
(www.jointcenter.org/hpi)
• Direct medical costs of
health inequalities
• Indirect costs of health
inequalities
• Costs of premature death
The Economic Burden of Health
Inequalities in the United States
• Between 2003 and 2006, 30.6% of direct medical care
expenditures for African Americans, Asian Americans,
and Hispanics were excess costs due to health
inequalities.
• Eliminating health inequalities for minorities would have
reduced direct medical care expenditures by $229.4
billion for the years 2003-2006.
• Between 2003 and 2006 the combined costs of health
inequalities and premature death were $1.24 trillion.
Geography and Health – the U.S.
Context
• The “Geography of Opportunity” – the spaces
and places where people live, work, study, pray,
and play powerfully shape health and life
opportunities.
• Spaces occupied by people of color tend to host
a disproportionate cluster of health risks, and
have a relative lack of health-enhancing
resources.
The Role of Segregation
Racial Residential Segregation – Apartheidera South Africa (1991) and the US (2010)
Source: Massey 2004; Frey 2011
100
95
Segregation Index
90
85
80
75
70
65
60
55
50
South
Africa
Detroit
Milwaukee New York
Chicago
Newark
Cleveland
United
States
Negative Effects of Segregation on Health
and Human Development
• Racial segregation concentrates poverty and
excludes and isolates communities of color from
the mainstream resources needed for success.
African Americans are more likely to reside in
poorer neighborhoods regardless of income
level.
• Segregation also restricts socio-economic
opportunity by channeling non-whites into
neighborhoods with poorer public schools, fewer
employment opportunities, and smaller returns
on real estate.
Negative Effects of Segregation on Health
and Human Development (cont’d)
• African Americans are five times less likely than
whites to live in census tracts with
supermarkets, and are more likely to live in
communities with a high percentage of fast-food
outlets, liquor stores and convenience stores
• Black and Latino neighborhoods also have fewer
parks and green spaces than white
neighborhoods, and fewer safe places to walk,
jog, bike or play, including fewer gyms,
recreational centers and swimming pools
Negative Effects of Segregation on Health
and Human Development (cont’d)
• Low-income communities and communities of
color are more likely to be exposed to
environmental hazards. For example, 56% of
residents in neighborhoods with commercial
hazardous waste facilities are people of color
even though they comprise less than 30% of the
U.S. population
• The “Poverty Tax:” Residents of poor
communities pay more for the exact same
consumer products than those in higher income
neighborhoods– more for auto loans, furniture,
appliances, bank fees, and even groceries
Metro Cleveland: Poverty Concentration of
Neighborhoods of All Children
Source: Diversitydata.org, 2011
100
90
80
70
60
Black
50
Hispanic
40
White
30
Asian
20
10
0
0%-20%
20%-40%
Over 40%
Metro Cleveland: Poverty Concentration of
Neighborhoods of Poor Children
Source: Diversitydata.org
80
70
60
50
Black
40
Hispanic
White
30
Asian
20
10
0
0%-20%
20%-40%
40% +
Metro Detroit: Poverty Concentration of
Neighborhoods of All Children
Source: Diversitydata.org, 2011
100
90
80
Black
70
Hispanic
60
50
White
40
30
Asian/Pacific
Islander
20
10
0
0%-20%
20%-40%
Over 40%
Metro Detroit: Poverty Concentration of
Neighborhoods of Poor Children
Source: Diversitydata.org
100
90
80
Black
70
Hispanic
60
50
White
40
30
Asian/Pacific
Islander
20
10
0
0%-20%
20%-40%
40% +
How can we eliminate health status
inequality?
Expand place-based opportunity:
• Reduce residential segregation by expanding housing
mobility programs (e.g., portable rent vouchers and
tenant-based assistance)
• Vigorously enforce anti-discrimination laws in home
lending, rental market, and real estate transactions
• Encourage greater commercial, business and housing
development in distressed communities
• Expand public transportation to connect people in jobpoor areas to communities with high job growth
How can we eliminate health status
inequality?
Improve public schools and educational
opportunities:
• Expand high-quality preschool programs
• Create incentives to attract experienced,
credentialed teachers to work in poor schools
• Take steps to equalize school funding
• Expand and improve curriculum, including better
college prep coursework
• Reduce financial barriers to higher education
How can we eliminate health status
inequality?
Create healthier communities:
• Address environmental degradation through
•
•
more aggressive regulation and enforcement of
laws and Consolidated Environmental Review
Structure land use and zoning policy to reduce
the concentration of health risks
Institute Health Impact Assessments to
determine the public health consequences of
any new housing, transportation, labor,
education policies
Expanding Housing Mobility Options:
Moving To Opportunity (MTO)
• U.S. Department of Housing and Urban Development (HUD)
launched MTO demonstration in 1994 in five cities: Baltimore,
Boston, Chicago, Los Angeles, and New York.
• MTO targeted families living in some of the nation’s poorest, highestcrime communities and used housing subsidies to offer them a
chance to move to lower-poverty neighborhoods.
• Away from concentrated poverty, families fare better in terms of
physical and mental health, risky sexual behavior and delinquency.
Adolescent girls benefited from moving out of high poverty more
than boys.
“[I]nequities in health [and] avoidable health inequalities
arise because of the circumstances in which people grow,
live, work, and age, and the systems put in place to deal
with illness. The conditions in which people live and die
are, in turn, shaped by political, social, and economic
forces.”
World Health Organization Commission on the Social
Determinants of Health (2008)
Health Inequities in Montana
Anna Whiting Sorrell, MPA, Director
Montana Department of Public Health & Human Services (DPHHS)
Jane Smilie, MPH, Administrator
Public Health and Safety Division, DPHHS
Social Determinants of Health
Inequities in Montana
• Some sources of inequity in Montana
– Low income/poverty
– Low educational attainment
– Medically underserved rural areas
• American Indians are more often affected
in our state
Social Determinants of
Health Inequities in Montana
100
Selected Social Determinants of Health Inequities in Montana
American Community Survey, 2008-2010
percent
80
60
40
32
20
13
11
4
0
Unemployed*
White
In poverty*
American Indian
Social Determinants of
Health Inequities in Montana
Access to Health Care
Montana BRFSS, 2010
100
80
percent
55
60
34
28
40
22
18
13
20
0
No insurance
Had to forego care
cost
White
due to
American Indian
No usual provider*
Inequities in Life Expectancy
in Montana
Median Age at Death
Montana Office of Vital Statistics, 2010
100
82
80
75
age in years
62
56
60
40
20
0
White
American Indian*
Men
White
American Indian*
Women
Leading Causes of Death
in Montana
Mortality from Chronic Disease
Montana Office of Vital Statistics, 2006-2010
age-adjusted per 100,000
300
250
260
215
200
150
124
101
84
100
65
50
75
45
0
Cardiovascular
disease*
Chronic respiratory
disease*
White
Lung
cancer*
American Indian
Colorectal
cancer*
Modifiable Risk Factors for
Chronic Diseases
Risk Factor for Chronic Disease
Montana BRFSS 2010
100
77
percent
80
61
49
60
32
40
20
21
16
0
Smoker*
Overweight or obese*
White
American Indian
No physical activity*
Cancer Incidence in
Montana
Cancer Incidence
Montana Central Tumor Registry, 2005-2009
127.0
age-adjusteed per 100,000
150
100.7
123.5
120
90
74.6
64.7
60
45.3
30
0
Breast (female)
Lung*
White
American Indian
Colorectal*
Cancer Screening
Participation in Montana
Cancer Screening Participation
Montana BRFSS 2010
100
83
72
80
78
71
percent
62
60
38
40
20
0
Colorectal cancer*
Breast cancer
White
American Indian
Cervical cancer
Critical Interventions for
Chronic Disease
• Tobacco cessation
• Risk factor management
– Weight
– Diabetes control
– Blood pressure
– Cholesterol
• Cancer screening
Outreach to American Indians
in Montana for Chronic Disease
• Funding
– All tribes and UICs for tobacco prevention
• Community-based educational campaigns
– Tobacco
– Heart attack and stroke awareness
• Technical assistance
– Blood pressure and cholesterol management
– Implement Diabetes Prevention Program
Outreach to American Indians
in Montana for Chronic Disease
• Cancer Screening
– Since 1996
– American Indian outreach initiated 2000
• MAIWHC
– Almost 1,200 American Indian women screened
for Breast and Cervical Cancer
• 19% of all screenings
– Colorectal screening added in 2010
Inequities in Pregnancy Risk
Factors in Montana
Risk Factors in Pregnancy
Montana Office of Vital Statistics, 2010
percent of live births
100
80
60
49
40
20
20
28
25
15
8
0
Teen pregnancy
(< 20 years)*
Prenatal care began after
1st trimester*
White
American Indian
Smoking in pregnancy*
Critical Interventions to
Improve Maternal and Child
Health
• Reduce teen pregnancy
– Access to highly effective contraceptives
– Promote delay in sexual activity
• Home visiting programs for high-risk
families
– Expectant parents
– Caregivers of infants and preschoolers
Outreach to American Indians
to Reduce Teen Pregnancy
• Working with two tribes to implement
teen pregnancy and STI prevention
curricula in middle and high schools
– New, pilot projects
– Draw the Line/Respect the Line
– Reducing the Risk
Outreach to American Indians
through Home Visiting
• Funding to every tribe for community
participation for development of
community-specific home visiting
programs
– Needs assessment
– Will promote smoking cessation
and early entry into prenatal care
Inequities in Communicable
Diseases in Montana
Sexually Transmitted Disease Incidence
Montana Communicable Diesease Epidemiology Program, 2010
1132
1200
crude rate per 100,000
1000
800
600
400
199
200
5
34
0
Chlamydia
White
Gonorrhea
American Indian
Critical Interventions to
Reduce Sexually
Transmitted Diseases
•
•
•
•
Screening and early detection
Case investigation
Contact tracing
Treatment including partner-delivered patient
therapy
Outreach to American Indians in
Montana for
Communicable Disease
• Work closely with Tribal Health Departments and
I.H.S. Units
– Screening
– Contact tracing
– Treatment
• Goals
– Prevent spread
– Prevent complications that have serious health
effects and lifelong consequences
Outreach to American Indians
to Reduce Vaccine-Preventable
Diseases in Montana
• Childhood Immunization
– VFC provides vaccines at no cost for
American Indian children
• Tribal clinics have higher up-to-date rates
– Tribal 68% of children fully immunized
– Statewide 52%
Summary and Conclusions
• American Indian residents experience more
barriers to improved health
• DPHHS effective outreach activities
– Community-based
– Proven-effective interventions
• Leadership
• Integrated into the work of all programs
Massachusetts Department of Public Health
The Elimination of Health Disparities –
A Public Health Priority
John Auerbach, MBA
Commissioner of Health
Why Should this be a
Priority?
HIV/AIDS Death Rate by Race/Ethnicity
Western Region and Massachusetts: 2006-2009
25
Black non-Hispanic
Hispanic
Asian non-Hispanic
19*
20
Deaths per 100,000
White non-Hispanic
29*
15
12*
10
8*
5
State
Overall:
NA 2.1
1*
1*
1*
0
Western Region
Massachusetts
Age-adjusted to the 2000 US standard population.
Source: MDPH, Bureau of Health Information, Statistics, Research, & Evaluation Bureau, Division of Research & Epidemiology
46
Asthma Emergency Department Visit Rates
Children Ages 0-14
Western Region and Massachusetts: 2008
White non-Hispanic
Hispanic
3,500
Black non-Hispanic
Asian non-Hispanic
3,294*
Visits per 100,000
3,000
2,364*
2,500
2,001*
1,937*
2,000
1,500
State
Overall:
958.2
1,000
637*
500
543*
578*
447*
0
Western Region
Massachusetts
* Statistically different from State (p ≤.05)
Age-adjusted to the 2000 US standard population.
Source: Division of Health Care Finance and Policy. Calendar Year 2008. Emergency Department Visits
47
Prevalence of Diabetes in Massachusetts Adults
Varies Significantly by Race/Ethnicity
Age-adjusted Prevalence
25
20
15
12.2
*
*
13.4
10
6.6
6.1
5
†
0
2010
White (NH)
Black (NH)
† Insufficient data
*significantly higher than White, NH
SOURCE: MA Behavioral Risk Factor Surveillance System (BRFSS), 2010
Hispanic
Asian
Total
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Additional Areas of Health
Disparity
Often intensifying racial and ethnic
disparities
Educational Level
15+ Days of Poor Mental Health in Past Mo. by Level of Education
20
15.4
Percent
15
11.1
11.6
10
5.7
5
0
<High School
High School
College 1-3 yrs
College 4+ yrs
50
Data Source: MA Behavioral Risk Factor Surveillance System - 2010
Disability Status
Females Who Report Sexual Violence by Age & Disability Status,
50
43.7
40
29.1
30
30.9
22.3
20.8
24.1
20
13.1
11.3
12.2
10
0
Disabled / Need help
Disabled
No Disability
18-44
45+
All Ages
51
Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS) – 2009-2010
What Causes These Disparities?
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Poverty is a Major Factor
Variation in Diabetes Prevalence Among Adults by
Household Income
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
<$25,000
$25,000-34,999
$35,000-49,999
$50,000-74,999
$75,000+
53
Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS)
Education is a Major Factor
Diabetes by Education,
Massachusetts Adults, 2010
25
20
Percent
16.2
15
10.4
10
8.0
7.4
4.8
5
0
< HS
HS grad
1-3 years college 4+ years college
MA
Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state 54
Source: MA Behavioral Risk Factor Surveillance System (BRFSS), 2010
The community-level obstacles to
healthier behaviors
In poorer neighborhoods:
– Healthy food less
available & affordable
– More fast food
restaurants and stores
that sell less healthy
foods
– Fewer parks, recreation
centers and safe places
to exercise
– More cigarette
advertising
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Deaths per 100,000 workers
Hispanic workers are at high risk of fatal
occupational injury in Massachusetts
5.0
4.0
4.0
3.0
2.0
2.0
1.0
0.0
White
Hispanic
Source: MA FACE and Census of Fatal Occupational Injuries, 2007-11
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Less access to health care
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Discrimination as a Factor
Racial/Ethnic Discrimination and Health: Findings From
Community Studies
David R. Williams, PhD, MPH, Harold W. Neighbors, PhD, and
James S. Jackson, PhD
“Perceptions of discrimination appear to
induce physiological and
psychological arousal, and, as is the
case with other psychosocial
stressors, systematic exposure to
experiences of discrimination may
have long-term consequences for
health. These experiences are part of
the social and psychological context in
which disease risk emerges and
within which effective interventions to
improve health must be embedded.”
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What Can be Done in Public
Health to Address the Issue?
Hire Diverse Leadership
After years of little diversity in leadership…
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Focus Attention at the Highest Levels
• Creation of DPH
Health Equity Office
• Management of
disparities and other
grants
• Involvement in senior
policy inside and
outside of DPH
• Use of the position as
a bully pulpit
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Provide Information on Disparities
Regulatory mandate
that hospitals collect
and report accurate,
consistent patient
race and ethnicity
data
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Issue
Special
Reports
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Promote Higher Quality Services…
“Making CLAS Happen”
CLAS (Culturally and
Linguistically Appropriate
Services) Standards (US DHHS, 2001)
• contribute to the elimination of
racial and ethnic health disparities
• make services more responsible
to the individual needs of clients
• are inclusive of all cultures, while
specifically designed to address
the needs of racial, ethnic, and
linguistic minority groups.
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Provide Specialized Funding, if possible
• Release of $1M dollars
to support innovative
efforts throughout the
state
• Adapt existing DPH
programs to reflect
focus on racial and
ethnic disparities (new
RFP criteria)
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Work with Local Communities
• Supporting local
screenings of Unnatural
Causes* to build
awareness about health
disparities.
• Working with
communities to develop
goals to eliminate
disparities in health.
*Unnatural Causes
Produced by California Newsreel
www.californianewsreel.org
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Develop Targeted Campaigns
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Focus on access to health insurance
% of MA Adults under 65 without Health Insurance,
by Race/Ethnicity, 2001-2010
Age-adjusted Prevalence
25
20
15
10
5
0
2001
2002
Hispanic
2003
2004
2005
Black
All percentages are age-adjusted to standard population (U.S. 2000)
Chart shows two-year moving averages
Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS)
2006
2007
Overall
2008
2009
2010
White
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Make the economic argument
• Poor health costs more –
higher premiums and
more out of pocket costs
• Poor adult health leads to
more absenteeism and
less productivity
• Poor children’s health
leads to more school
absenteeism and dropouts
• TFAH Report; RWJ grant
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For more information, please contact:
◦ Meenoo Mishra, MPH, Senior Analyst of Health
Equity at [email protected]