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Should We Be Done With Describing Health Disparities?


September 17th, 2014

A recent Health Affairs podcast featured a conversation with AcademyHealth president and CEO Lisa Simpson on health disparities along with Darrell Gaskin, the lead of one of the panel sessions at the 2014 National Health Policy Conference (NHPC), “Community Health and Disparity: Moving Beyond Description.” The conversation endorses interventions rather than descriptions as the future direction of health disparities research.

But should we be done with describing health disparities? In a paper we recently published online in the International Journal for Equity in Health, we show that the answer is: Not entirely.

In this paper, using large, publicly available data, 2008, 2009, and 2010 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan/Micropolitan Area Risk Trends (SMART) and 2008, 2009, and 2010 United States Birth Records from the National Vital Statistics System, we reported education-, sex-, and race-related disparities in four health outcomes (poor/fair health, poor physical health days, poor mental health days, and low birthweight) in each of the selected 93 counties in the United States representing about 30 percent of the U.S. population.

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Same Care No Matter Where She Gives Birth: Addressing Variation In Obstetric Care Through Standardization


September 12th, 2014

In August, Health Affairs published a study highlighting an alarming fact in maternal health: The incidence of childbirth complications varies significantly from hospital to hospital across the United States. The study – led by Laurent Glance and colleagues at the University of Rochester – found that “women delivering vaginally at a low-performing hospital had twice the rate of any major complications than women delivering vaginally at a high-performing hospital.” The difference in these complication rates for cesareans was five-fold.

It is well known that variation in care contributes to higher rates of mortality and morbidity in all areas of health care, explaining the push toward checklists and other quality improvement tools and interdisciplinary collaboration. Identifying the primary reasons for variation in obstetric complication rates – why women giving birth in high-performing hospitals have lower complications rates – could be critical to understanding the reasons behind the increasing rates of maternal mortality and morbidity in the U.S. This study, along with other disturbing statistics, underscores the significant need for improvements in maternity care.

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Advancing Innovation To Eliminate Health Disparities


September 4th, 2014

The advent of population health management, community-based care coordination and mobile health technologies provide a promising opportunity to address longstanding and persistent health disparities. Separately each adds a new dimension to research and analysis, and to individual and community-level public health prevention and access to quality care. Together, providers, payers and researchers alike can acquire a richer understanding of contextual, environmental, and behavioral factors that contribute to disparate outcomes in health.

Existing innovations in data capture, epidemiologic profiling, clinical translation, and workforce development have yet to be taken to scale or appropriately deployed in a manner that would benefit vulnerable populations. Meaningful use technologies, for example, appear to be stuck in the proverbial pipeline with resistance in uptake and limited distribution of incentives. Meaning access and application in poor and disparate communities where they are more often subjects of research and not partners in innovation is far off.

What public health, and community-based and clinically focused interventions need is a fresh look at how health disparities are measured and the processes for application of solutions to needy populations.

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Exhibit Of The Month: Income-Related Disparities Associated With Negative Health Outcomes


August 29th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

Much is known about income-related disparities when it comes to preventative care and chronic conditions, but less so about the associations between poverty and negative health outcomes.

In “Geographic Clustering Of Diabetic Lower-Extremity Amputations In Low-Income Regions Of California,” published in the August issue of Health Affairs, authors Carl Stevens et al. identify diabetic amputation “hot spots” in low-income urban and rural areas of California (Exhibit 2).

Based on California data from 2009, they isolated 7,973 lower-extremity amputations in 6,828 adults with diabetes. They compare this to a corresponding map of poverty rates in the same region based on households who reported incomes below 200 percent of the poverty level (Exhibit 3).

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Health Affairs August Issue: Variations In Health Care


August 4th, 2014

Health AffairsAugust variety issue includes a number of studies demonstrating variations in health and health care, such as differing obstetrical complication rates and disparities in care for diabetes. Other subjects in the issue include the impact of ACA coverage on young adults’ out-of-pocket costs; and how price transparency may help lower health care costs.

For mothers-to-be, huge differences in delivery complication rates among hospitals.

Four million women give birth each year in the United States. While the reported incidence of maternal pregnancy-related mortality is low (14.5 per 100,000 live births), the rate of obstetric complications is nearly 13 percent.

Laurent Glance of the University of Rochester and coauthors analyzed data for 750,000 obstetrical deliveries in 2010 from the Healthcare Cost and Utilization’s Nationwide Inpatient Sample. They found that women delivering vaginally at low-performing hospitals had twice the rate of any major complications (22.55 percent) compared to vaginal deliveries at high-performing hospitals (10.42 percent

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Disparities In Access To Palliative Care


July 30th, 2014

Editor’s note: Otis Brawley also coauthored this post. This post is part of a periodic Health AffairsBlog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Racial and ethnic disparities in health care have been well documented among minority groups with respect to access to care, receipt of care, and quality of care. As a result of these disparities, minority populations are often diagnosed with late stage illness and have inferior outcomes likely leading to increased suffering.

Little is known, however, about disparities in access to and use of specialty palliative care. Palliative care is medical care aimed at relieving suffering and providing the best possible quality of life for people facing pain, symptoms, and stresses from serious illness. Palliative care is appropriate for patients at any age or illness stage and can be provided along with curative or life-prolonging therapies.

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Taking Stock Of The ACA: The Latest Data From The Health Reform Monitoring Survey


July 29th, 2014

Editor’s note: In addition to Sharon Long, this post is coauthored by Genevieve Kenney, Stephen Zuckerman, and Katherine Hempstead. 

Since early last year, the Urban Institute’s Health Reform Monitoring Survey (HRMS) has been collecting relevant, timely data that is providing insights on the implementation of the ACA and changes in health insurance coverage and related outcomes. (An article describing the survey was published in Health Affairs last December.)

Beginning in late 2013, the HRMS set the stage by exploring adults’ understanding of key ACA provisions, their level of health insurance literacy, and expectations about coverage changes in 2014 based on information collected just before the beginning of the first open enrollment period. More recently, the HRMS has shed light on the characteristics of the newly insured, identified who’s not shopping for insurance, and explained how some states’ decisions to expand Medicaid has reduced uninsurance rates.

The HRMS and other surveys have confirmed that the number of uninsured adults has declined significantly since the first open enrollment under the ACA started. On Tuesday July 29th 2014, Health Affairs Editor-in-Chief Alan Weil moderated a panel discussion on what the HRMS shows about the ACA’s performance thus far and what it implies for next year’s open enrollment period. (A recording is available for those who couldn’t join live.) At the event, we released three new policy briefs that, respectively, provide the latest detailed coverage estimates, describe the remaining uninsured, and explore how consumers are navigating the ACA’s Marketplaces.

Here’s a sample of what we’ve learned from this latest release of HRMS data and what was covered at today’s event:

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Washington Wakes Up To Socioeconomic Status


July 11th, 2014

John Mathewson, executive vice president of Health Care Services for Children with Special Needs (HSC) – a Medicaid managed care plan in D.C. for children on Supplemental Security Income (SSI) – recently spoke at the Association for Community Affiliated Plans (ACAP) CEO Summit before the July 4 Recess.

Mathewson described what he has dubbed The Kitten Paradox: When HSC examined environmental factors for children with asthma, it found that the presence of pets in the house was a common thread, not too far behind having a smoker around. Yet, it turns out the value a cat brings by protecting from mice or spawning a litter for sale outweighs any financial costs to the family associated with an ER visit, which are often free or carry a low copayment. Thus the paradox.

An awardee at the conference, Hennepin Health, catalogued the evidence showing that reliable housing can improve health outcomes, including improving mental health and lowering emergency room and inpatient hospital utilization.

The focus of these sessions was the social determinants of health, and a lot of these safety net health plan leaders’ heads were nodding throughout. The plans, which disproportionately serve Medicaid enrollees and thus ‘dual eligible’ seniors in Medicare, know something about the importance of social determinants that the health policy community – at least in Washington – is only now slowly waking up to.

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ACAView: New Findings On The Effect Of Coverage Expansion Since January 2014


July 9th, 2014

Editor’s note: In addition to Josh Gray, Iyue Sung also coauthored this post. 

Together, athenahealth and the Robert Wood Johnson Foundation (RWJF) have undertaken a new joint venture called ACAView, as part of the foundation’s Reform by the Numbers project, a source for timely and unique data on the impact of health reform.

The goal of ACAView is to provide current, non-partisan measurement and analysis on how coverage expansion under the Affordable Care Act (ACA) is affecting the day-to-day practice of medicine. athenahealth provides a single-instance, cloud-based software platform to a national provider base.

Any information that our clients enter using our software is immediately aggregated into centrally hosted databases, providing us with timely visibility into patient characteristics, clinical activities, and practice economics at medical groups around the country.

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New Offices Of Minority Health At FDA And CMS: Will They Help Eliminate Disparities In Health?


June 19th, 2014

Given the rocky roll-out of healthcare.gov, the end of the open enrollment period brought surprising good news: over eight million Americans signed up for coverage through the new Health Insurance Marketplaces. Three million previously uninsured young adults are now covered through their parents’ policies and six million more are enrolled in Medicaid and the Children’s Health Insurance Program.

Minorities are disproportionately more likely to be uninsured, and continued expansions in coverage will help significantly to close gaps in care. However, the impact of the Affordable Care Act (ACA) will not be limited to coverage. A number of provisions to address disparities were included in the ACA, relating to community health, workforce, and data collection. In addition, the ACA authorized new offices of minority health to lead and coordinate federal and national efforts to improve health and reduce disparities.

Several operating divisions at the U.S. Department of Health and Human Services (HHS), including the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, had existing offices dedicated to improving the health of vulnerable populations. However, this was not the case for the Food and Drug Administration (FDA) or the Centers for Medicare & Medicaid Services (CMS).

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Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

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Exhibit Of The Month: Racial Disparities In Clinical Studies


May 27th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibit, published in the May issue of Health Affairs, illustrates losses to follow-up among black men in clinical studies due to incarceration. Their findings, based on certain National Heart, Lung and Blood Institute cohort studies, raise concerns regarding the generalizability of clinical research.

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Traditional Budgeting Fails To Account For The Changing Face Of America


May 23rd, 2014

The United States has been undergoing a major demographic shift over the past four decades, and by 2042, the various “minority” communities will in the aggregate make up the majority of our country.  That has real implications not only for things like immigration policy, but also – and critically – for population health considerations.  And it’s time that Congress started thinking about its health policy decisions in ways that recognize this coming demographic reality.

In 2012, there were more than 53 million Latinos living in the United States – up 50 percent from 2000, and up 600 percent from 1970.  This trajectory is even starker when we note that, in the United States as a whole, the population grew just 12 percent from 2000 to 2012.  Today, meanwhile, African Americans are about 13 percent of the population, and that population grew 15 percent from 2000 to 2010.

If current trends continue, there will be 133 million Latinos and nearly 66 million African Americans in the U.S. by 2050, meaning nearly one in two Americans in 2050 will be African American or Latino.

Why does this matter to health policy and the federal budget?  Because these ethnic groups have different health challenges and realities, and those, in turn, have very real economic consequences.

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Health Policy Research And Disparities: A Health Affairs Conversation With Lisa Simpson And Darrell Gaskin


May 22nd, 2014

Earlier this year, AcademyHealth held its 2014 National Health Policy Conference; Health Affairs was a media partner for the NHPC. In a new installment of our Health Affairs Conversations Podcast series, we talk about the conference, as well as the challenges and opportunities facing the health services and health policy research communities, with AcademyHealth president and CEO Lisa Simpson. Before taking the helm of AcademyHealth, Dr. Simpson was director of the Child Policy Research Center at Cincinnati Children’s Hospital Medical Center and professor of pediatrics in the Department of Pediatrics, University of Cincinnati. She served as the Deputy Director of the Agency for Healthcare Research and Quality from 1996 to 2002.

We also take a close look at one of the NHPC sessions: “Community Health and Disparity: Moving Beyond Description.” (The disparities session is freely available to all readers.) Darrel Gaskin, who led the panel discussion, joins us as well. He is Deputy Director of the Johns Hopkins Center for Health Disparities Solutions and Vice Chair of AcademyHealth’s Board of Directors

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Immigration And The ACA: Will Differing State Systems Offer A Controlled Experiment In Extending Coverage To Immigrants?


May 7th, 2014

Immigration and health care reform remain controversial issues, and their intersection remains fraught with complexities. Immigration reform that would provide a pathway to legalization for the 11-12 million unauthorized immigrants in the country is stalled in Congress.  Some of the fundamental controversies surrounding the Affordable Care Act (ACA) have, however, been settled, and the law is well into implementation. Now is a good time to focus on how the ACA is affecting and might affect health coverage, costs, and outcomes for various populations, including immigrants.

In addition to federal support for health coverage, the ACA is also ushering in an era of increased state experimentation. The law allows states to open their own insurance marketplaces or participate in the federal marketplace, and with last year’s Supreme Court decision, to decide whether or not to expand Medicaid for low-income childless adults. The law may also open opportunities for states to experiment with coverage options for the one major group excluded from the ACA: unauthorized immigrants.

Unauthorized Immigrants and the Affordable Care Act

ACA excludes the unauthorized from the marketplaces and eligibility for federal subsidies to purchase health insurance. According to the Migration Policy institute, an estimated 7-8 million unauthorized immigrants are currently uninsured, due to low employer coverage and ineligibility for Medicaid and other public programs; the unauthorized represent between one-fifth and one-sixth of the total 40-45 million uninsured. Their uninsurance rate ranges widely from state to state, peaking at over 70 percent in a number of Southeastern and Southwestern states.

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What Lies Ahead For US Hospitals? May Health Affairs Explores Post-Recession And ACA Environments


May 5th, 2014

Health Affairs’ May issue examines a number of concerns facing US hospitals in the wake of the recession and implementation of the Affordable Care Act (ACA). Several papers also analyze trends in US health care spending. Several of the authors of articles addressing hospital concerns will present their work at a National Press Club briefing on Wednesday, May 7.

Per capita health care spending growth for males outpaced females, while the oldest continued to spend the most from 2002–2010. David Lassman of the Centers for Medicare and Medicaid Services and colleagues examined personal health care spending in the United States for selected years from 2002–2010 and found that the average elderly person spent $18,424—three times more than working-age adults and five times more than children.

Yet the annual growth in spending for people ages sixty-five and older increased at the slowest annual rate (4.1 percent) and for children it was the fastest (5.5 percent). Growth in spending for males outpaced females, driven by a closing of the gender gap across most payers and goods and services, but most dramatically for prescription drug spending. The researchers also discussed the impacts of aging baby boomers, the recession, and the implementation of Medicare Part D during this period.

EDs are already money makers for hospitals, and the ACA could push profits even higher. Michael Wilson of Harvard Medical School and David Cutler of Harvard University examined 2009 hospital financial reports and patient claims data and found a 7.8 percent profit margin that year in emergency department (ED) revenue over costs, or $6.1 billion. They found that the profits stemmed largely from privately insured patients, compensating for underpayments from other groups.

Of the 120 million ED visits analyzed, 35 percent of patients were privately insured, 26 percent were covered by Medicaid, 21 percent by Medicare, and 18 percent were uninsured. As more Americans gain insurance through the ACA, hospital-based EDs stand to increase their profit margins with a changing insurance payer mix. Policy makers looking to reduce health care costs, say the authors, should be cognizant of the dependence of ED profitability on payer mix and its implications for hospital-based accountable care organizations with varied patient populations.

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Beyond Access: High Quality Care For All


April 30th, 2014

In medical school, I had an epiphany about my role as a doctor during my obstetrics-gynecology rotation at the county safety-net hospital in Fresno, California. I loved the thrill and satisfaction of delivering babies, but after about 10 births, it hit me that virtually all the women for whom I had delivered babies were teenage girls, as young as 13. They and their children would face uphill battles. As a clinician, I was too often a cog in a machine, fixing immediate needs but not addressing underlying problems to prevent poor health outcomes.

The Affordable Care Act tears down a fundamental barrier preventing vulnerable populations from accessing care by reducing the number of uninsured and underinsured Americans. But expanded access to coverage will not, by itself, guarantee high quality care for all. It would be a serious mistake to assume that insurance will eliminate disparities in health outcomes. In Chicago, a person with diabetes living in an African American neighborhood is five times more likely to have his or her leg amputated than a person living in a white neighborhood. Insurance alone won’t close that gap. Indeed, many who needlessly lose limbs are already insured.

I have spent a great deal of my career caring for inner city patients and working with other professionals to research the health of the public. If we really want to end disparities in the health care system, here are some things we should be doing:

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Narrative Matters: Lost In Translation: To Our Chinese Patient, Alzheimer’s Meant ‘Crazy And Catatonic’


April 28th, 2014

In the April Health Affairs Narrative Matters essay, when cultural perceptions get in the way, a Chinese geriatrician and his colleagues find a way to care for a patient newly diagnosed with dementia. Xinqi Dong and E-Shien Chang’s article is freely available to all readers, or you can listen to the podcast.

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Connected Health Opportunities For Medicaid’s Most Vulnerable Patients


April 22nd, 2014

The February issue of Health Affairs features a series of articles on connected health and highlights the potential for telehealth and telemedicine to reshape how health care is delivered, consumed, tracked, and even paid for.

With funding support from Kaiser Permanente Community Benefit, the Center for Health Care Strategies (CHCS) recently conducted a series of focus groups that showed how one key Medicaid population — medically and socially complex, low-income individuals — stands to gain from these advances.

The four focus groups were designed to better understand the issues driving these individuals’ health care utilization, their current level of comfort with technology, and how technology might be able to help them better manage their challenges. Participants were actively receiving services from of one of four case management/care coordination programs in New York City, Long Island, the Hudson Valley, and Philadelphia, and all were Medicaid beneficiaries with multiple medical and/or behavioral health conditions.

According to a recent Health Affairs article by John Billings and Maria Raven, these individuals frequent emergency departments and have a high incidence of chronic disease. They typically have chaotic, unstable, and socially isolated lives, and many lack permanent housing, live on the street, or in homeless shelters.

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Health Reform And Criminal Justice: Advancing New Opportunities


April 1st, 2014

Community Oriented Correctional Health Services (COCHS) and Health Affairs invite you to join thought leaders from public safety, health care, philanthropy, and all levels of government to further explore the intersection of health reform and criminal justice. As implementation of the Affordable Care Act continues, it is time to take stock of how far we have come in addressing the needs of the jail population through policy and planning, and to set our direction for the future.

This national event will take place on Thursday, April 3, from 8:00 a.m. to 4:00 p.m., at the Columbus Club in Union Station, Washington, D.C. It is being organized with support from the Robert Wood Johnson Foundation, the Jacob & Valeria Langeloth Foundation, and Public Welfare Foundation. Registration for in-person attendance is closed, but a live webcast is available.

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