Citizens’ Health Care Working Group Adela S. Valdez M.D. Past Presiding Officer Health Disparities Task Force Asst. Dean for Education, UTHSCSA-RAHC.

Citizens’ Health Care Citizens’ Health Care Working GroupWorking Group

Adela S. Valdez M.D.Adela S. Valdez M.D.Past Presiding Officer Past Presiding Officer

Health Disparities Task ForceHealth Disparities Task ForceAsst. Dean for Education, UTHSCSA-RAHCAsst. Dean for Education, UTHSCSA-RAHC

Citizens’ Health Care Working GroupCitizens’ Health Care Working Group

ObjectivesObjectivesReview how HDTF and DSHS approached Review how HDTF and DSHS approached

Health Disparities with overview of Hispanic Health Disparities with overview of Hispanic Health DisparitiesHealth Disparities

Review organizational processes utilized to Review organizational processes utilized to address Health Disparities address Health Disparities

Highlight best practicesHighlight best practices

Lessons learnedLessons learned

Review HDTF and DSHS Review HDTF and DSHS approach to Health approach to Health

DisparitiesDisparities

Priority Health Areas - USDHHSPriority Health Areas - USDHHS

Infant mortalityInfant mortality CancerCancer Cardiovascular diseaseCardiovascular disease DiabetesDiabetes HIV/AIDSHIV/AIDS ImmunizationsImmunizations

OMH AND HDTF InitiativesOMH AND HDTF Initiatives

ImmunizationsImmunizations

Obesity and Diabetes Prevention( CA, CV Obesity and Diabetes Prevention( CA, CV disease)disease)

Physical Activity and Fitness (CV disease)Physical Activity and Fitness (CV disease)

Tobacco Use (Cancer prevention)Tobacco Use (Cancer prevention)

Responsible Sexual Behavior (HIV/AIDS)Responsible Sexual Behavior (HIV/AIDS)

Prenatal Care (Infant mortality)Prenatal Care (Infant mortality)

Burden of Chronic Burden of Chronic Diseases andDiseases andRacial/Ethnic Racial/Ethnic DisparitiesDisparities

Causes of Death in United States-2000Causes of Death in United States-2000

32,844

2,214

2268

3,436

3,597

5,445

7,735

7,854

10,596

33,437

43,100

Number of deaths

All Other Causes

Suicide

Nephritis, Nephrotic Syndrome and Nephrosis

Alzheimers Disease

Pneumonia and Influenza

Diabetes Mellitus

Chronic Lower Respiratory Diseases

Accidents

Cerebrovascular Diseases

Malignant Neoplasms

Diseases of the Heart

0 10,000 20,000 30,000 40,000 50,000

Texas, 2001

LEADING CAUSES OF DEATH

ObesityObesity

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2002BRFSS, 2002

America’s Fattest Cities - 2004America’s Fattest Cities - 2004

The Perfect StormThe Perfect Storm

Lifestyle Changes that Promote Lifestyle Changes that Promote Sedentary BehaviorSedentary Behavior

Tobacco Prevention and ControlTobacco Prevention and Control

Tobacco remains the single most Tobacco remains the single most preventable cause of death and disease in preventable cause of death and disease in Texas and the USTexas and the US

Over 24,000 Texans Die each yearOver 24,000 Texans Die each year

Cost of over $10 Billion dollars Cost of over $10 Billion dollars

In 1998, about 15% of all Texas Medicaid In 1998, about 15% of all Texas Medicaid expendituresexpenditures

Success of Success of TobaccoTobacco

InterventionIntervention

Trends in Cigarette Smoking PrevalenceTrends in Cigarette Smoking Prevalence

Plan to resolve the problemPlan to resolve the problem

Appropriate Funds allocated into six main Appropriate Funds allocated into six main components:components:– Community and School based Community and School based – Public AwarenessPublic Awareness– Cessation efforts with QuitlineCessation efforts with Quitline– Efforts targeting specific populationsEfforts targeting specific populations– Youths in alternate settingsYouths in alternate settings– Enforcement of tobacco control policiesEnforcement of tobacco control policies

Pilot initiatives in four East Texas CountiesPilot initiatives in four East Texas Counties– Jefferson, Harris, Fort Bend, and MontgomeryJefferson, Harris, Fort Bend, and Montgomery

ResultsResults

After first two years of implementationAfter first two years of implementation36% reduction in 636% reduction in 6thth-12-12thth grade tobacco grade tobacco users in East Texasusers in East Texas~ 55,000 fewer 6~ 55,000 fewer 6thth – 12 – 12thth graders using graders using tobacco products as result of the tobacco products as result of the comprehensive programcomprehensive program18.6 % reduction in adult smoking rates 18.6 % reduction in adult smoking rates which translates to 90,000 fewer adult which translates to 90,000 fewer adult smokers in the areasmokers in the area

Overview of Hispanic Overview of Hispanic Health DisparitiesHealth Disparities

CHANGING POPULATION DEMOGRAPHICSCHANGING POPULATION DEMOGRAPHICS

EDUCATIONEDUCATION

Hispanics and Blacks, in general, are Hispanics and Blacks, in general, are disproportionately undereducated.disproportionately undereducated.School drop-out rates are excessively School drop-out rates are excessively high.high.SAT scores for Hispanic and Black SAT scores for Hispanic and Black students are relatively low.students are relatively low.Enrollment in early childhood education Enrollment in early childhood education programs (Head Start, kindergarten) programs (Head Start, kindergarten) disproportionately low.disproportionately low.

HEALTH PROFESSIONALSHEALTH PROFESSIONALSGENERALGENERAL

Hispanics and Blacks are Hispanics and Blacks are disproportionately underrepresented in disproportionately underrepresented in virtually ALL the health professions.virtually ALL the health professions.

The underrepresentation involves those in The underrepresentation involves those in practice, academia, research fields, post-practice, academia, research fields, post-baccalaureate degrees.baccalaureate degrees.

HISPANICS IN DECISION-MAKING HISPANICS IN DECISION-MAKING POSITIONSPOSITIONS

Major disparity in the number/proportion of Major disparity in the number/proportion of Hispanics and Blacks in decision-making Hispanics and Blacks in decision-making positions in the health professions, positions in the health professions, state/national bodies, business sector, state/national bodies, business sector, educational sector, governmental sector, educational sector, governmental sector, etc.etc.

HEALTH INSURANCEHEALTH INSURANCE

Hispanics and Blacks in U.S. and Texas Hispanics and Blacks in U.S. and Texas are disproportionately underinsured and are disproportionately underinsured and uninsured.uninsured.

This problem is greater among Hispanics This problem is greater among Hispanics in the Southwest and even greater still in in the Southwest and even greater still in communities closer to the U.S.-Mexico communities closer to the U.S.-Mexico border.border.

Texas Has the Highest Uninsured Rate in the Nation

15%

25%

Total U.S. Texas

Percent Uninsured

Majority of Uninsureds Are Employed

25%

7% 68%Employed

Percent Texas Uninsured by Labor Status

Not in Labor Force

Unemployed

80% of Uninsured

Hispanics Are Employed

HEALTH INSURANCEHEALTH INSURANCE

Texas ranks 2Texas ranks 2ndnd among states in the among states in the percentage of children 0-17 years old who percentage of children 0-17 years old who do not have public or private health do not have public or private health insurance. insurance.

44 % of the uninsured children in Texas 44 % of the uninsured children in Texas are Hispanic.are Hispanic.

Source: Office of Public Insurance Counsel

HEALTH INSURANCEHEALTH INSURANCE

For migrant children who are actually enrolled in For migrant children who are actually enrolled in the Texas Medicaid program, the coverage the Texas Medicaid program, the coverage becomes moot as soon as they leave the state.becomes moot as soon as they leave the state.

Lack of health insurance affects access to health Lack of health insurance affects access to health services, contributes to poorer health, higher services, contributes to poorer health, higher hospitalization rates and more advanced hospitalization rates and more advanced disease state by time health services finally disease state by time health services finally received.received.

Hispanics Typically Low Utilizers of Healthcare Services

Lower Utilization of HealthcareLower Utilization of Healthcare

• Culture - Home remedies commonly first line of defense.Culture - Home remedies commonly first line of defense.

• Reactive vs Proactive HealthcareReactive vs Proactive Healthcare

• Women set the health agenda in the household.Women set the health agenda in the household.

Fewer Hispanic PhysiciansFewer Hispanic Physicians

• Only 13% of the state’s 13,000 primary care physicians are Hispanic.Only 13% of the state’s 13,000 primary care physicians are Hispanic.

DIABETES (ADULT-ONSET TYPE)DIABETES (ADULT-ONSET TYPE)

Higher rate of diabetes for Hispanics and Higher rate of diabetes for Hispanics and BlacksBlacks

Higher rate of diabetic complicationsHigher rate of diabetic complications

Higher death rates for Hispanics and Higher death rates for Hispanics and Blacks, 2 to 2.5 times higher than Anglos Blacks, 2 to 2.5 times higher than Anglos in 1990 and 2000 in Texasin 1990 and 2000 in Texas

DISEASE/HEALTH DISPARITIESDISEASE/HEALTH DISPARITIESHOMICIDESHOMICIDES

Homicide rate for Hispanic and Black Homicide rate for Hispanic and Black males was 2 to 4 times higher than that for males was 2 to 4 times higher than that for Anglo males in Texas in 1990 and 2000. Anglo males in Texas in 1990 and 2000. (Rates among females are similar (Rates among females are similar between Hispanics and Anglos.)between Hispanics and Anglos.)

Age-Adjusted Death Rates for Age-Adjusted Death Rates for Cervical Cancer by Race/Ethnicity, Texas: 1995-1998Cervical Cancer by Race/Ethnicity, Texas: 1995-1998

(Rate per 100,000 population)(Rate per 100,000 population)

3.0

5.8

8.4

0

1

2

3

4

5

6

7

8

9

White, NH Hispanic Black, NH

Source: Texas Department of Health, Vitalnet

SCREENING FOR BREAST CANCERSCREENING FOR BREAST CANCER

Rates for breast examination by a clinician Rates for breast examination by a clinician are lower in Hispanic and Black females.*are lower in Hispanic and Black females.*

78.8% White, non-Hispanic78.8% White, non-Hispanic 57.5% Hispanic 57.5% Hispanic 75.7% Black, non-Hispanic75.7% Black, non-Hispanic

*Data for 1998-2000*Data for 1998-2000

SCREENING FOR BREAST CANCERSCREENING FOR BREAST CANCER

Rates for mammography are lowest for Rates for mammography are lowest for Hispanic femalesHispanic females

61.0% Hispanic 61.0% Hispanic 72.1% Black, non-Hispanic72.1% Black, non-Hispanic 71.5% White, non-Hispanic71.5% White, non-Hispanic

*Data for 1998-2000*Data for 1998-2000

DISEASE/HEALTH DISPARITIESDISEASE/HEALTH DISPARITIESTEENAGE PREGNANCYTEENAGE PREGNANCY

Hispanic and Black teenage pregnancy rate 2 to Hispanic and Black teenage pregnancy rate 2 to 3 times higher than that for White non-Hispanics.3 times higher than that for White non-Hispanics.

Percent unmarried (2/3 of teenage pregnancies) Percent unmarried (2/3 of teenage pregnancies) is similar between Hispanics and White non-is similar between Hispanics and White non-Hispanics.Hispanics.

Percent unmarried (about 94 percent of teenage Percent unmarried (about 94 percent of teenage pregnancies) much higher for Blacks.pregnancies) much higher for Blacks.

Rates over the last decade relatively stable.Rates over the last decade relatively stable.

DISEASE/HEALTH DISPARITIESDISEASE/HEALTH DISPARITIESOBESITYOBESITY

Being overweight and obesity are Being overweight and obesity are disproportionately increased in Hispanics disproportionately increased in Hispanics and Blacks, particularly females.and Blacks, particularly females.

DISEASE/HEALTH DISPARITIESDISEASE/HEALTH DISPARITIESMENTAL HEALTHMENTAL HEALTH

Need more frequency information, risk Need more frequency information, risk factors, mental health care access, factors, mental health care access, outcomes in Hispanics and Blacks in outcomes in Hispanics and Blacks in Texas and in the U.S.Texas and in the U.S.

SUMMARYSUMMARY

Rapidly growing numbersRapidly growing numbers

Increased under-education, low income, Increased under-education, low income, language barrierslanguage barriers

Greater lack of access, underutilization, Greater lack of access, underutilization, mis-utilization of health care systemmis-utilization of health care system

Greater uninsured, underinsuredGreater uninsured, underinsured

REPRESENTATIVE HEALTH REPRESENTATIVE HEALTH POLICY IMPLICATIONSPOLICY IMPLICATIONS

Expansion of health insuranceExpansion of health insuranceIncreased inclusion of Latinos and Blacks Increased inclusion of Latinos and Blacks in medical/health research as consumers, in medical/health research as consumers, researchersresearchersIncreased numbers of Latinos and Blacks Increased numbers of Latinos and Blacks in Academic Health institutions in Academic Health institutions (administration, tenured faculty, (administration, tenured faculty, researchers)researchers)

REPRESENTATIVE HEALTH REPRESENTATIVE HEALTH POLICY IMPLICATIONSPOLICY IMPLICATIONS

Enhancement of early educational Enhancement of early educational opportunities.opportunities.

Dramatic focus needed in eliminating Dramatic focus needed in eliminating disparities in access to care, utilization of disparities in access to care, utilization of care, and preventive services.care, and preventive services.

CHALLENGESCHALLENGES

Increasing health care costsIncreasing health care costs

Lack of societal mandate for all to have sufficient Lack of societal mandate for all to have sufficient access to the health systemaccess to the health system

Increased expectations of health with increasing Increased expectations of health with increasing technologytechnology

Improving health requires improving education, Improving health requires improving education, employment, decision-making capacity in a employment, decision-making capacity in a variety of community and organizational sector.variety of community and organizational sector.

SUMMARYSUMMARY

Major under representation in health Major under representation in health professionalsprofessionals

Major under presentation in decision-making Major under presentation in decision-making bodies in health, government, business, bodies in health, government, business, education, entrepreneurs—arenas that intersect education, entrepreneurs—arenas that intersect with health and health carewith health and health care

Numerous health disparities (i.e., Numerous health disparities (i.e., disproportionately greater disease burden)disproportionately greater disease burden)

Less health and research data availableLess health and research data available

New Innovative InitiativesNew Innovative Initiatives

State Program InitiativesState Program Initiatives

Regional InitiativesRegional Initiatives

Texas State Heath Strategic PartnershipTexas State Heath Strategic Partnership

StrategiesStrategies

Eliminating health disparities in Eliminating health disparities in Texas requires an ability to identify Texas requires an ability to identify and address the underlying causes and address the underlying causes of higher levels of disease…of higher levels of disease…

StrategiesStrategies

Research is needed to understand Research is needed to understand why vulnerable populations have why vulnerable populations have disparate health outcomes…disparate health outcomes…

StrategiesStrategies

Improved Access / OutreachImproved Access / Outreach Enhanced public informationEnhanced public information Community partnershipsCommunity partnerships Realignment of funding prioritiesRealignment of funding priorities

Underlying Causes of DisparityUnderlying Causes of Disparity

RaceRace EthnicityEthnicity GenderGender AgeAge GeographyGeography EducationEducation

Small Steps,Small Steps,BIG ImpactBIG Impact

Linking potential external partners to Linking potential external partners to SHS programsSHS programs

Promoting SHS programs that improve Promoting SHS programs that improve the health of racial/ethnic minorities to the health of racial/ethnic minorities to the health care community, in addition to the health care community, in addition to the public and private sectorsthe public and private sectors

Each Region is addressing problems in Each Region is addressing problems in their own communitiestheir own communities

StrategiesStrategies

Texas Public Health Regions

Community Outreach Community Outreach

Promotora Community OutreachPromotora Community Outreach

3-Share Plan3-Share Plan

Health Benefits PackageCo-sponsored by the Galveston Chamber of Commerce and the University of Texas Medical Branch

Jan-May June July Aug Sep Oct Nov Dec Jan Feb Mar April May June July Aug Sep Oct

20042004 20052005

Certify and Enroll Business Partners and Patient Base(3000-4000 patient population)

Program DevelopmentSecure State

Approval3-Share Clinic Start-up

3-Share Clinic Ongoing Service/Evaluation and Policy

Development

Working Uninsured Project –Working Uninsured Project –Access to HealthAccess to Health

• Target low income workers (median in family income $30,000 per year)

• Premium sharing – employee, employer and government (1/3 each – estimated premium $50-75 per month per individual)

• Focus on wellness, provide physicals and pharmacy benefits* In Texas, 28% of the population lacks health insurance

What TI is DoingWhat TI is Doing

Designing disease management programs that have Designing disease management programs that have relevance for each employeerelevance for each employeeParticipating in a multi-company research project in Participating in a multi-company research project in conjunction with the Washington Business Group on conjunction with the Washington Business Group on Health to better understand employee perceptions Health to better understand employee perceptions about health care and employees’ experiences with about health care and employees’ experiences with health care providers. The study will help to provide health care providers. The study will help to provide information about correlations between health care information about correlations between health care delivery and the impact of health care disparity on delivery and the impact of health care disparity on health outcomeshealth outcomes

Texas Instruments is focusing on addressing theissue of health care disparity by:

What TI is Doing (cont.)What TI is Doing (cont.)

Working to use our influence in the local Working to use our influence in the local business community to increase awareness of business community to increase awareness of health care disparity. Ultimately we want health care disparity. Ultimately we want employers to begin to make specific employers to begin to make specific requirements of health plans/carriers:requirements of health plans/carriers:– 1) Diversity of networks1) Diversity of networks– 2) Cultural proficiency in the delivery of health 2) Cultural proficiency in the delivery of health

education programseducation programs– 3) Data tracking of disease outcomes based on race3) Data tracking of disease outcomes based on race

What TI is Doing (cont.)What TI is Doing (cont.)Helping to increase the awareness of the need Helping to increase the awareness of the need for cultural competency for health care providersfor cultural competency for health care providers

Ensuring health plan physician panels have Ensuring health plan physician panels have diversity representationdiversity representation

Encouraging health plan carriers to begin Encouraging health plan carriers to begin addressing health care disparitiesaddressing health care disparities

Texas State Strategic Health Texas State Strategic Health Partnership GoalsPartnership Goals

Promoting health nutrition and physical activityPromoting health nutrition and physical activity Promoting health choices with regard to risky Promoting health choices with regard to risky

behaviorbehavior Recognizing mental health as a public health issueRecognizing mental health as a public health issue Increasing rates of high school graduation, adult Increasing rates of high school graduation, adult

literacy and college attendance to improve literacy and college attendance to improve socioeconomic and health statussocioeconomic and health status

Reducing health threats due to environmental and Reducing health threats due to environmental and consumer hazardsconsumer hazards

Reducing infectious diseaseReducing infectious disease

Texas State Strategic Health Texas State Strategic Health Partnership GoalsPartnership Goals

By 2010, Texas state statue and local policy will By 2010, Texas state statue and local policy will ensure that essential public health services ensure that essential public health services ( emphasizing disease/injury prevention and ( emphasizing disease/injury prevention and health promotion) are available for all health promotion) are available for all communities in Texas.communities in Texas.By 2010, a diverse set of governmental and non-By 2010, a diverse set of governmental and non-governmental partners will actively participate governmental partners will actively participate and collaborate to provide the services and collaborate to provide the services necessary to meet the public health needs of necessary to meet the public health needs of TexasTexasBy 2010, Texas communities will be aware of By 2010, Texas communities will be aware of the structure, function, and availability of the the structure, function, and availability of the public heath system. public heath system.

Presidential Advisory Presidential Advisory Commission onCommission on

Educational Excellence for Educational Excellence for Hispanic AmericansHispanic Americans

Three Major StrategiesThree Major Strategies

Cooperation / CollaborationCooperation / Collaboration

FOCUS – High Yield PracticeFOCUS – High Yield Practice

Communicate–Communicate-CommunicateCommunicate–Communicate-Communicate

Do Something About It....Do Something About It....wplwpl

The Health of The Health of Texas…Texas…

……Is up to Us.Is up to Us.