Wednesday, January 31, 2018

At Health Action 2018, a focus on racial discrimination in healthcare

Last week I attended Health Action 2018, Families USA's annual gathering of healthcare advocates, ACA navigators, healthcare wonks and politicos.  I have a post in progress probing where the conference suggests Democrats may be headed next on the healthcare front.

One piece of that puzzle is how directly Democrats focus on equity issues -- specifically racial and ethnic inequities.  These present something of a political conundrum in that, as longtime former Senate aide (and healthcare adviser in the Obama administration ) Chris Jennings put it, "equity doesn't sell."  Proposals pitched to help the disadvantaged, Jennings asserted, arouse suspicions among many that others' gain will be their loss. People value programs that seem to treat everyone equally. "Medicare for all" polls well because it's perceived as a system that all pay into and all benefit from.

Notwithstanding that reality -- or perceived reality -- Families USA, to its credit, is training its focus on equity issues, and the conference reflected that in two plenary sessions in particular. Below is an an outtake of sorts from my broader conference overview in progress, focused on those panels -- and on Cory Booker's speech, which also focused on equity.

Cory Booker: Shame today, justice tomorrow

After a brief salute to the success of activists who beat back ACA repeal, Booker straight in on equity issues.  "We can savor the progress we've made, but so much more work to do. We still live in a nation where people make decisions between buying prescription drugs and paying rent or buying food for their families...where the maternal death rate is higher than any industrialized nation and the racial disparities within that are women are three to four times more likely to die in childbirth, their children twice as likely....we have a nation where certain ethnic groups are in crisis, where  40% of native Americans who die of heart disease are under 65...there are so many data points that should hang like a shame in country that boasts such high ideals and has so much wealth."

Ever the preacher, Booker offered a "prayer for all of us"...that our children/grandchildren look back at this era today and say, wow, look at tine when people didn't have access to healthcare. He continued: "we need to make the reality we're living in America now something future generations will look back at and won't understand how it could have ever been." That's a caustic twist on Pericles' boast to an Athens on the brink of ruinous civil war: "Future generations will marvel at us."

President Obama's master frame for American history was the drive toward "a more perfect union" -- a constant effort to live up to the ideals expressed in the nation's documents, punctuated with setbacks, but making continual progress. Here too Booker offered a more acerbic version, quoting from Langston Hughes' Let America Be America Again:

America never was America to me,
And yet I swear this oath—
America will be!

Racism, written in the body

The spotlight Booker trained on racial disparities was picked up in an afternoon plenary session, Racial Discrimination and Health Care. Dr. Camara Jones of the Morehouse School of Medicine defined racism as "a system of  assigning value based on the social interpretation of how one looks. To illustrate, she pointed to her own appearance viewed through three lenses: "I look plainly black in the U.S., plainly white in Brazil, and colored in South Africa." If she stayed in any of those countries, "my health outcome would match."

David Williams of  Harvard's Chan School of Public Health fleshed out disparate outcomes statistically, citing a study finding that at a California hospital with bone fractures, 55% of Hispanics who arrived with a bone fracture were given no analgesia, compared to 26% of non-Hispanic whites. Turning to the social determinants of health, Williams asserted that residential discrimination is  "the secret sauce that drives discrimination in America. Zip code is a stronger predictor of how long and how well you live than genetic code. He cited research finding that in America's 100 largest metro areas, 76% of African American children and 58% of Latino children live in places wore than the worst neighborhoods whites live in.

Through the looking glass in Puerto Rico

Another session focused on inequity, "Tale of a Block Grant: Notes from the Puerto Rico Health Crisis," also spotlighted the effects of Republicans' favored vehicle for healthcare "reform" --  capping the amount the federal government gives to each state each year to meet its Medicaid commitments. Such "block grants" are designed to grow according to a fixed formula rather than adjusting to needs as they manifest themselves.

Before Hurricane Maria struck, Sinsi Hernandez-Cancio of Families USA noted, Medicaid in Puerto Rico had been block-granted for 50 years -- and was chronically underfunded. The island has had to make do with "run down hospitals. People with money go to the States when they get sick. Nurses take collections so patients can have soap. There's a cottage industry in which people pay women to sit with family members in the hospital.  Patients have to bring their own blankets and pillows. And there are no nursing homes.

Dr. Carmen Zorrilla of the University of Puerto Rico reported that Hurricane Maria, triggered a  complete disruption hospital care for more than month, with very partial services restored in months following. The storm interrupted cancer surgery and chemotherapy for months.

James Torres of Latinos for Healthcare Equity detailed the math of the island's radical long-term shortfall in Medicaid funding. Funding is capped at $300 million per year for 1.6 million enrollees. The federal match rate -- the share of enrollees' costs picked up by the federal government before the cap kicks in -- is 55%, compared to 75% in Mississippi, the nation's poorest state. While the ACA granted a temporary cash infusion --  $6.3 billion through 2019 -- hundreds of thousands stand to lose coverage when that funding runs out.

As Republicans strive to convert Medicaid in the states to block grants or impose per capita caps,  Eliot Fishman of Families USA warned, "Puerto Rico is on the other side of the looking glass in those debates -- a cautionary tale for what we're fighting and what we will continue to be up against."

Where does equity fit in?

The fact that I'm posting an account of these sessions as an outtake suggests that I may be reproducing the problem that Jennings identifies (or perhaps embodies): putting equity issues in the background when focused on where next-gen health reform may be heading. All I can say is I'll keep that in mind while proceeding.

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