Speech on the Need for Health Care Reform
Speech by Wade Henderson on September 15, 2009 at the Agency for Healthcare Research's Quality Annual Conference 2009
Thank you, Carolyn, for that gracious introduction. And thank you all for coming to this conference and devoting several days to examining how we can do more to improve access to quality health care for everyone.
I'm particularly pleased to be here with Dr. Clancy, with whom I serve on the board of directors of the National Quality Forum. NQF is dedicated to improving the quality of health care for all by developing national consensus standards for measuring and reporting on performance, setting goals for improving care, and helping us attain those goals through public outreach and education.
As you just heard, I'm President of the Leadership Conference on Civil Rights. We're the nation's oldest, largest, and most diverse civil and human rights coalition. I'm also proud to say that I'm the Joseph L. Rauh, Jr. Professor of Public Interest Law at the University of the District of Columbia.
We all know that disparities in access to quality care and the resulting prevalence of illness are woven through the entire health system and throughout the American landscape. I couldn't possibly address all of the issues, so in the interest of keeping the speeches short and the discussion long, I'm going to limit myself to four topics:
First, why we in the civil rights and advocacy community consider health care to be a core civil and human rights issue that impacts everything we do and must accomplish to achieve true civil rights and social justice.
Second, what is happening out there now, as illustrated by one powerful and emblematic example of the problems of discrimination in the health care system.
Third, I'll give you an example of what you and your colleagues in the public health and research communities are already doing and describe how federal legislation can help support it.
Finally, I'll discuss what federal health care reform must accomplish to make quality health care accessible and affordable to everyone and in every community.
Health Care is a Civil and Human Rights Issue
Why do we insist that healthcare is a fundamental civil rights issue? Because healthcare is inextricably linked to every aspect of social and economic justice.
When people lack access to quality and affordable healthcare, a medical emergency can bankrupt a family. As long as families face this danger, they have no economic security. Without access to quality and affordable healthcare, chronic medical problems can prevent a worker from changing or keeping jobs and advancing at work, which destroys equal employment opportunity. Without access to quality and affordable health care, poor health can keep a child out of school, which denies that child educational opportunity
The sad truth is that health disparities begin before birth and last a lifetime. Hispanic and African-American women are more than twice as likely as White women to receive only very late prenatal care or none at all. Native American women are more than three times as likely to do without adequate prenatal care.
Given the racial and ethnic disparities in prenatal care, it is not surprising that there are similar racial disparities in low birth-weight babies. In fact, African-American women are twice as likely as White women to give birth to low-weight babies.
In our nation's cities, these disparities are even worse than the national averages. Here in our nation's capital, Washington, D.C., White women have even better access to early prenatal care, but both Black and Hispanic women are less likely to have access to care. Minority women in the District are over 3.5 times more likely to go without first trimester prenatal care than White women. The incidence of low-weight births among Black women in the District of Columbia is almost triple the rate for White women.
These racial disparities continue, and often increase, during children's school years. Since Brown v. Board of Education, access to quality education has been a focus of the civil rights movement, and rightly so. I'm sure we can all agree that until we provide quality education to all children, regardless of their race or income, we have virtually no chance of achieving true and lasting racial and social justice.
But, once again, access to healthcare is essential for real educational opportunity.
Studies conducted without regard to race have shown direct links between prenatal health care and childhood health. Education research has demonstrated direct connections between children's health, children's school attendance, and long-term academic achievement. If we know that low-income and minority women do not have access to quality prenatal care, then we know that their children will be less healthy, attend fewer days of school, and achieve less academically.
Just think about two seemingly unrelated problems that are plaguing school-aged children in this country. In addition to visiting family physicians and dentists, children need to be examined by eye doctors. How is even the brightest child going to learn to read and write and do mathematics if she can't see properly? And how will she be able to see properly if she has undiagnosed and untreated nearsightedness or astigmatism? What if the difference between success and failure is simply a pair of eyeglasses?
Perhaps the most dangerous long-term health crisis facing the nation is the obesity epidemic, with its profound array of economic and health consequences. While there is no official definition of obesity for children, the numbers of overweight children have skyrocketed over the last three decades.
According to the National Center for Health Statistics, the percentage of overweight adolescents has increased two and a half-fold, from six percent in 1974 to 15 percent in 2002. Among elementary school children, the rate has nearly quadrupled, from four percent to 15 percent. Those numbers double to 30 percent if you include children who are deemed "at risk" of becoming overweight. The overall numbers are alarming for all Americans, but they are far worse for minority children, with African-American and Latino youth approximately twice as likely to be overweight than their White counterparts.
Being overweight has profound and immediate health consequences for children. It results in chronic conditions such as diabetes, asthma, high blood pressure and cholesterol, sleep apnea, and a wide range of bone and joint problems. All of these health problems impose catastrophic costs on families and further detract from a child's ability to learn.
Fast forward a few years, and all these problems diminish the opportunities of mature workers, just as they shrink the futures of our children.
When adult Americans can't see properly, have chronic medical conditions, and have received inadequate educations, they have trouble qualifying for good jobs, keeping good jobs and moving ahead in their careers. When they are too old to work, they are less likely to have adequate pension plans. And they also have a harder time just providing for themselves – much less accumulating and passing along family wealth from generation to generation.
Discrimination in New York Hospital Clinics
How is this civil rights issue playing out in today's health care system? The effects of discrimination in health care can destroy individual lives and condemn whole communities to inequalities that infect their social and economic fabric. So, what is the face of intentional discrimination today? One example, both shocking and routine, was exposed in the 2005 report "Separate and Unequal: Medical Apartheid in New York City."
In a practice common to hospitals across the country, many hospitals in New York City sort patients for their out-patient specialty clinics, sending the privately-insured to the hospitals' top-flight "faculty practices," but seeing Medicaid and uninsured patients only in their regular clinics. Despite being operated by the same hospital – sometimes even in the same offices, just at different times – the two types of clinics follow very different rules.
Faculty practice care is provided by experienced board-certified doctors; clinic care is from a rotating crew of residents still getting their medical training. Faculty practice patients have 24-hour phone access and continuity of care from their personal physicians in and out of the hospital; clinic patients are left to fend for themselves after-hours, consigned to the emergency room with unknown doctors who are unfamiliar with their medical history. If admitted, they'll have a third set of doctors, which makes continuity of care impossible.
This intentional form of economic discrimination creates racial discrimination and health disparities because minorities are more than twice as likely to be uninsured or on Medicaid in New York City. And it sends a clear message to doctors, staff, and patients that it is people of color who can be treated as "practice-patients" and sent to these lower-quality clinics.
Expecting Success: Research and Solutions for Health Disparities
So what are we doing right? We know what the problem looks like, but what do the solutions look like? The professions represented here today have created a blueprint that should raise hope that we can eliminate health disparities in this country. In 2005, the Robert Wood Johnson Foundation introduced a project called "Expecting Success: Excellence in Cardiac Care," run by Dr. Bruce Siegel, the director of the Center for Health Care Quality at George Washington University.
Expecting Success collected race, ethnicity and language data on cardiac patients at 10 hospitals and analyzed the quality of the care that all patients received based on accepted and well-understood best-practice standards for cardiac care. The hospitals were chosen based on their diversity in every way – size, patient demographics, hospital type; and they were spread across the country, from El Paso to Detroit and Washington, D.C., to Hollywood…well, Hollywood, Florida, but you get the idea.
The first thing they did was devise a uniform system for collecting race, ethnicity and primary language information for every patient. They asked. Sounds simple, but there was significant anxiety about this from admissions staff to hospital leaders. Was it legal? Would patients be offended? Were the hospitals' computer systems capable of handling the information?
It turned out to be easy. It's entirely legal; people are used to answering demographic questions and don't assume there is anything nefarious going on; and it was a small change for the hospitals' IT departments to add the data fields.
The hospitals could then analyze 23 cardiac care quality indicators by patient race, ethnicity and language. They found significant disparities, and they also found serious failures to provide the best quality care across the board.
But what's more important is that armed with that data, all 10 hospitals immediately went to work to improve quality and ensure that all patients started getting the best care. When they saw that poor transitions between hospital and ambulatory care settings were a problem – and that minority patients were far more likely to have gaps in their care – they brought inpatient and outpatient centers together to provide continuity and improve follow up.
In area after area, the results were remarkable. Without the data, no one would have believed or admitted that congestive heart failure patients weren't getting help quitting smoking, but in one hospital only 32 percent of the patients got smoking cessation counseling. Confronted with that data, the hospital changed and even before the study ended, 100 percent of patients got the counseling.
The lowest performing hospital in the study increased the percentage of patients who received all of the recommended standards of care for heart failure by ten-fold, while the all-hospital median rose from 41 percent to 78 percent.
For coronary angioplasty, the door-to-balloon time at one hospital improved by 60 percent in the first year and they routinely hit the 90-minute target time for 100 percent of heart attack patients.
Initially, the lowest performing hospital met the standard for providing all recommended care to its heart attack patients only about 20 percent of the time. Faced with that evidence, it improved to 80 percent in two years. And the best performing hospital went from 90 to 100 percent – which may not sound like much, but let's remember that this is not just a numbers game. Providing 100 percent of patients with the ideal standard of care is the best way to guarantee that health disparities have been completely eliminated.
What's the moral of this story? Good data – good disaggregated data – is essential for breaking through the natural systemic defensiveness and denial that there is a problem, for understanding the scope of the problem, and for building the will to solve the problem.
It's a lesson we learned a long time ago in the civil rights community. And a pattern that repeats itself over and over again, from employment discrimination to juvenile justice to access to a quality public education – think about how much the education debate has changed in the last few years, now that we know the real data about the academic achievement and graduation gaps.
It's why the Leadership Conference and our health care task force, which is led by Debra Ness from the National Partnership for Women and Families, successfully fought to require that race, ethnicity, gender and language fields be included in the health information technology provisions of the American Recovery and Reinvestment Act – the stimulus package that was signed into law in February.
What We Must Do Next
So, what's the next step? Comprehensive health care reform is on the table, but what must we do to ensure that it addresses our concerns as civil rights advocates and advocates for underserved patients? In the civil rights community, we are fighting to expand access, eliminate discrimination and make sure that the reforms are financed in an equitable way that won't undermine the lofty and long-overdue goal of universal coverage.
We are trying to expand access to Medicaid and ensure meaningful subsidies for people left to buy insurance on the marketplace, regardless of whether they are buying a private plan or any type of public option. In Medicaid, we're fighting for a hard floor of 133 percent of the poverty line for eligibility in every state and for every class of potential beneficiaries.
For federal subsidies to individuals, we're seeking an eligibility-level of three to four times the poverty line and a cap on premiums at 12.5 percent of income. In real dollars, this would mean that for a family of four earning $30,000, a so-called "bronze plan" would be reduced from the impossible to afford price of $11,600 to a more manageable $2,320.
We are seeking enforceable antidiscrimination provisions that would end the intentional discrimination based on insurance status that I described earlier – we succeeded in the House bill but there is still work to be done in the Senate.
And we are fighting against an abomination known as the "free rider" provision – a discriminatory financing measure that would pervert the "pay or play" concept of employer responsibility. Under free rider, rather than paying a fee based on the total size of its workforce, an employer that doesn't provide health insurance benefits would only have to pay for the number of lower-income employees who actually took the federal subsidy to help them pay for buying their own insurance. Free rider would create a powerful incentive for employers to discriminate against workers from low-income families, minorities, and especially single mothers. An employer hiring for that $30,000 job would save the entire $9,280 subsidy if he turned down the single mother and hired someone without kids or whose spouse had a decent job.
So this terrible piece of health care policy wouldn't just cost lower-income workers and their children access to the insurance and health care that they need, it would cost them their jobs too. We succeeded in knocking it out of the Senate health committee bill, and are working to stop the Senate finance committee's version from making it into the final legislation.
And that brings us back to where I began: access to health care – and the federal policies that affect it – are woven into the fabric of civil rights, economic empowerment, and social justice. It's why the civil rights community is engaged and energized; and it's why we need to seize this moment and harness the creativity and ingenuity that have advanced the science of medicine and apply them to making these modern miracles accessible and affordable for everyone.
Thank you very much for having me here and I look forward to continuing the discussion.