Lauren A. Underwood and Antonia M. Villarruel “Inequality is as dear to the American heart as liberty itself.” —William Dean Howells Health disparities refer to differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that may exist among specific population groups (P.L. 106-525, 2000; United States Department of Health and Human Services [U.S. DHHS], 2000). Health disparities have been documented between genders, among groups with different educational levels, and among different age groups. From a policy perspective, priority population groups in the United States include racial and ethnic minorities, persons from low socioeconomic backgrounds, women, children, older adults, and those living in rural areas (AHRQ, 2009). In this chapter we will discuss policies related to racial and health disparities. The Report of the Secretary’s Task Force on Black and Minority Health by the U.S. DHHS Secretary’s Task Force on Black and Minority Health (1985) led to a significant policy focus on health disparities. This landmark report identified disparities seen in U.S. blacks, Hispanic, Asian/Pacific Islander, and Native American populations. For example, 80% of excess mortality experienced by minority groups is linked to causes of death including cancer, cardiovascular disease, diabetes, infant mortality, unintentional injury, and chemical dependency. Importantly, the Task Force made eight specific recommendations that have served as a blueprint for subsequent policy to address these disparities (Box 22-1). Significant policy initiatives stemming from this report include data requirements for federal data-collection systems to collect race and ethnicity data, the requirement to include racial and ethnic minorities in federally funded research (NIH, 1994), and the establishment of the Office of Minority Health within the Office of Secretary at the U.S. DHHS (Office of Minority Health, 2009). Since the 1985 Secretary’s Report, several additional key policy initiatives and reports have had a major impact in the effort to address health disparities. Perhaps the boldest policy initiative related to health disparities occurred with the unveiling of Healthy People 2010: Understanding and Improving Health (U.S. DHHS, 2000), a comprehensive set of disease prevention and health promotion objectives for the nation. As one of only two overarching goals for the decade, this initiative called for the elimination of health disparities. The Healthy People 2010 goal is significant as it directed government-sponsored initiatives to monitor and address health disparities in their programs. Another important report addressing disparities in health care was Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Smedley et al., 2003), issued by the Institute of Medicine. A key finding from the report was that “Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable” (p. 6). Notable findings from this report document that racial and ethnic minorities received lower-quality health care within the United States, even after controlling for insurance status, income, and other access factors (Smedley et al., 2003). The report presented multilevel recommendations to address health care disparities ranging from patient-provider interventions as well as interventions addressing the health system and federal policy. To support the federal directive to monitor progress related to the elimination of disparities in health and health care, the Agency for Healthcare Research and Quality (AHRQ) annually publishes the National Healthcare Disparities Report (AHRQ, 2009). This report monitors the nation’s progress toward eliminating disparities in health care, which are the differences in the quality of and ability to access health care services for different populations (AHRQ, 2004). Data are presented on quality measures including effectiveness, patient safety, timeliness, efficiency, and patient centeredness, as well as components of access to health care. The corresponding database NHQRDRNet is publicly available on the AHRQ website (nhqrnet.ahrq.gov) to allow direct access to the dataset from which this report is based. In addition to federal and state governments, private foundations have also prioritized the investigation and elimination of health disparities. For example, the Kaiser Family Foundation has sponsored a number of policy reports such as Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level (James et al., 2009). This document describes the persistence of disparities domestically, providing a comprehensive state-level examination of disparities across race and ethnicity for a broad range of indicators of health and well-being. The complexity and challenges associated with eliminating racial disparities in health are evident by examining disparities in infant mortality. Hispanic, American Indian/Alaska Native, and African-American groups have all historically had elevated infant mortality rates compared with both non-Hispanic whites and the national average (National Center for Health Statistics [NCHS], 2008). While there have been dramatic decreases in infant mortality rates for whites, ethnic minority groups have not experienced similar decreases. A nation’s infant mortality rate is considered a significant indicator of population health, given its relationship with and sensitivity to maternal health, public health services, access to quality health care, and socioeconomic status (MacDorman & Matthews, 2008). The causes of infant mortality and related disparities are multifaceted and result from the intersection of genetic, environmental, and behavioral factors (Behrman & Butler, 2007). There are three main conditions that contribute to infant mortality: congenital abnormalities, Sudden Infant Death Syndrome (SIDS), and conditions related to short gestation and low birth weight (MacDorman & Matthews, 2008). Preterm birth, and low birth weight factors are potentially preventable during the prenatal period (Lang & Iams, 2009; Ashton et al., 2009; Lee et al., 2009). Consequently, policy solutions and evidence-based interventions predominantly focus on addressing low birth weight, preterm birth, and SIDS. Long recognized as a problem, particularly in African-American and other racial and ethnic minority populations regardless of socioeconomic status, there have been a variety of policy solutions offered by governmental and nongovernmental organizations at all levels to address the infant mortality disparities. We describe two policy interventions: the Nurse Family Partnership and the Children’s Health Insurance Plan. The Nurse Family Partnership (NFP) is an evidence based program designed to improve pregnancy outcomes, improve child health and development, and improve parental life course (Olds, 2006). The program is structured around a series of home visits by registered nurses beginning in the first two pregnancy trimesters and ending with the child’s second birthday. Outcomes of the program have included fewer verified cases of child abuse and neglect, lower numbers of subsequent pregnancies, fewer abortions, longer time between the births of the first and second child, and fewer months utilizing public assistance programs including welfare and food stamps (Olds, 2006). In 2003, an economic analysis of the NFP estimated costs to be approximately $8000 for 2.5 years of service, but the return on investment, as it relates to health outcomes and cost savings, is estimated at $17,000 (Olds, 2006; Olds et al., 2007). The combination of improved infant and child outcomes, long-term cost savings, and popularity of the NFP across municipalities has led to federal support of the NFP and similar nurse home visitation programs. The president’s FY 2010 budget request contains funding to support services to approximately 50,000 families, with plans to expand the program to some 450,000 families (U.S. DHHS, 2009; Administration for Children and Families, 2009). Continued federal support of programs to improve prenatal outcomes for high-risk and low- income individuals could lead to a substantial reduction in African-American infant mortality. Since its congressional authorization in 1997, states across the country have utilized the Children’s Health Insurance Program (SCHIP) as a tool to expand health insurance coverage for children, including infants in their first year of life (Centers for Medicare & Medicaid Services [CMS], 2009) (see Chapter 18). SCHIP covers pregnant women and children, facilitating access to health care services, including important health teaching and screening activities that can identify and reduce risk factors for SIDS and other sequela associated with preterm birth and low birth weight. SCHIP is a Medicaid expansion designed to provide health coverage to uninsured children whose families are in income brackets above Medicaid eligibility limits (Center for Children and Families, 2009). Basic eligibility is set by the federal government through the Medicaid program, and specific program eligibility standards are established by individual states to fit their unique needs, priorities, and funding abilities (CMS, 2009). Reauthorized by Congress in 2009, the renamed Children’s Health Insurance Program (CHIP) includes a new state option to cover pregnant women through 60 days postpartum (Center for Children and Families, 2009). Under this provision, states cannot impose preexisting condition limitations or enact waiting periods before pregnant women become eligible for care. Children born to women receiving pregnancy-related health care services through this option will be automatically enrolled in CHIP until that child turns one year old (Center for Children and Families, 2009). These policy stipulations will enable states to target high-risk pregnant women and connect them with the needed basic prenatal and supplementary services including case management and home visitation programs. States have flexibility in eligibility determination, outreach strategies, and reimbursement criteria, and they have the opportunity through the CHIP program to create a multiagency (e.g., CHIP, Medicaid, WIC) infrastructure to support community efforts to reduce infant mortality (Center for Children and Families, 2009). The issue of racial and ethnic health disparities is interwoven within a domestic history of discrimination and enacted laws meant to maintain privileges. As can be seen, efforts to address health disparities include broad public health policy in addition to targeted intervention-based programs for those most affected by health disparities. Moving forward, policy will need to focus on achieving health equity, a positive way to address disparity and inequality. Health reform and the challenges of expanding access to health insurance to millions of uninsured individuals will need to simultaneously emphasize quality of health care as a way to reduce disparities. The renewed focus on primary care, investments in health information technology, and emphasis on evidence-based practices via comparative effectiveness policies are all federal attempts to improve the quality of health care across the country. Prevention and a reinvestment in public health will also likely address health disparities issues, particularly for disparities occurring as a result of environmental exposures, geographic location, and chronic disease. Nursing expertise will be critical to implement the needed health system reforms, and our continued professional involvement with research, advocacy, community outreach, and policy will help ensure that even underserved populations’ health challenges are addressed. However, to successfully eliminate health disparities, a broad range of policy solutions must be developed. Systemic efforts to increase the level of education, ensure meaningful work opportunities, and provide safe and secure housing are important ancillary policy areas that must be addressed for the sustained elimination of health disparities. For a list of related websites, please refer to your Evolve Resources at http://evolve.elsevier.com/Mason/policypolitics/
Policy Approaches to Address Health Disparities
Health Disparities Reports and Policies
Health Disparities in Infant Mortality: a Contemporary Example
Nurse Family Partnership
Children’s HEALTH Insurance Program
Summary
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