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© The Wellesley Institutewww.wellesleyinstitute.com
Health Equity Lessons from…the United States? Really?
Matt Kanter
December 16, 2009
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Outline of Presentation
• Health Equity Statistics in the U.S.
• Discuss Current U.S. Health Care Reform
• State and Local Equity Initiatives• Massachusetts
– The City of Boston
• California
• New Jersey
• Possible Lessons for Canada
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Health Equity in the U.S.
• Canadians’ perceptions of the American health care system
• Medical expenditures are the leading cause of personal bankruptcies in the U.S.
• What could the U.S. possibly teach Canadians about Health Equity?
• First, the statistics…
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Health Equity in the U.S.: The Uninsured
• 17.4% of non-elderly Americans are uninsured (45.7 million people)
• 32% of those considered “low-income” lack health insurance
• 10.3% of children are uninsured
• 20.6% of African-Americans and 32.2% of Hispanic Americans do not have insurance
• 18.8% of non-elderly workers are uninsured
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Health Equity in the U.S.: Health Spending
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Health Equity in the U.S.: Health Spending
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Health Equity in the U.S.: Health Outcomes
• Life Expectancy:• U.S.: 78.1 years
• Canada: 80.7 years
• OECD Average: 79.0 years
• The U.S. also has vast disparities in health care quality and outcomes across race, ethnicity, SES, gender, place of residence (urban vs. rural) and language (Institute of Medicine)
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Current U.S. Health Care Reform Explained
• (1) The Political Process: Where are We?
• (2) The Basics of Reform (H.R. 3962)
• (3) Forgotten (Ignored?) Health Equity Elements of the Proposed Legislation
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Health Care Reform: The Process
• House: Blended Bill passed November 7, 2009 (220 – 215)
• Senate: Blended bill introduced on November 18, 2009; No vote yet
• What’s Next? If it passes the senate, a joint House/Senate Committee will re-write the bill which must pass both houses and be signed by the President
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Health Care Reform: The Basics
• Individual Mandate – With Subsidies
• Employer Mandate
• National Health Insurance Exchange– With a Public Option?
• Key Changes to Private Insurance
• Paying for the Legislation/Cost Containment
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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives
Health Disparities Definition (in H.R. 3962):
“‘Health Disparities’ includes health and health care disparities and means population specific differences in the presence of disease, health outcomes or access to care”
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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives
• ss. 1221 – 1223: Concerned with reducing language barriers for limited-English-proficiency populations
• Sec 1442: The Secretary shall ensure that reducing health disparities is an explicit goal in her national priorities for quality improvement in health care
• Sec 2251: The Secretary shall establish a cultural and linguistic competency training program for health professionals
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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives
• Sec 2301: The CDC shall establish a program for the delivery of community based-preventive/wellness services
– At least 50% of the funds must be spent on planning/implementing wellness services whose primary purpose is to achieve a measurable reduction in one or more health disparities
• Sec 2402: The Department of HHS shall establish the position of Assistant Secretary for Health Information
– The Assistant Secretary shall “facilitate and coordinate identification and monitoring of health disparities…to inform program and policy efforts to reduce health disparities”
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State and Local Equity Initiatives: Massachusetts
Chapter 58 of the Acts of 2006
• Based on the premise of shared responsibility– Included an individual mandate with subsidies for low-income
individuals, an employer mandate and a state-wide insurance exchange (called “The Connector”)
• 2 years after implementation, 439,000 people had signed up for health insurance
– The uninsurance rate dropped from 11% in 2005 to 2.6%
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Massachusetts Continued
• The MA legislation also contains several provisions which deal explicitly with reducing health disparities
• Legislation creates a Health Disparities Council
• It also requires a study on the possibility/cost-effectiveness of using CHWs to reduce racial/ethnic health disparities
• Subsequently, MA developed an Office of Health Equity within the State Department of Health and Human Services
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State and Local Equity Initiatives: The City of Boston
• First U.S. city to establish a comprehensive plan to eliminate racial and ethnic health disparities (2005)
• Disparities Project made 12 recommendations, including:– (1) Requiring health care organizations to gather uniform patient data on race,
ethnicity, language and SES
– (2) Developing skills to enable community members to become better informed and equipped patients
– (3) Providing cultural competence education and training to health care professionals
– (4) Increasing resources to improve workforce diversity
– (5) Increasing public awareness about health disparities
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Boston Continued
• One year into the Project, significant results, including:
– Significant progress toward building a uniform data collection system
– More than 460 health care professionals completed cultural competency training
– Approximately 3,000 people were directly involved in targeted community-wide education, training and advocacy;
– 3,000 more received direct patient education and support
– The Boston Neighborhood Network (BNN) created an 8-segment TV series about the Disparities Project
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State and Local Equity Initiatives: California
Health Care Language Assistance Act (SB 853) – Key Elements
• Health plans must conduct a needs assessment to calculate threshold languages and collect race, ethnicity and language data
• Health plans must provide quality, accessible and timely access to interpreters at all points of contact in the health care system and at no cost to the enrollee
• Health plans must translate vital documents into threshold languages
• Health plans must ensure that interpreters are trained, competent and that translated materials are of high quality
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State and Local Equity Initiatives: New Jersey
• In 2005, NJ became the first state to develop mandatorycultural competency training for physicians
• SB 144 requires medical professionals to receive cultural competency training to graduate from a NJ med school or to get (or renew) a license to practice medicine
• Improving cultural competence is widely recognized as integral to the reduction of health disparities
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Potential Lessons for Canada
• (1) Create an Office of Health Equity
• (2) Need Uniform Data Collection and Analysis
• (3) Recruit a Diverse Workforce
• (4) Need Collaboration Among Stakeholders
• (5) The Importance of Quality, Trained Health Care Interpretation
• (6) Increased Cultural Competency Training
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Questions and Discussion
Any questions/comments?
Paper available here: http://www.wellesleyinstitute.com/files/Health%20Equity%20Lessons%20from%20the%20US%20-%20Formatted%20v.3_1.pdf