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TESTIMONY OF DAVID SATCHER, ASSISTANT SECRETARY FOR HEALTH AND SURGEON GENERAL
U.S. PUBLIC HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND SOCIAL SERVICES
BEFORE THE HOUSE COMMERCE COMMITTEE, SUBCOMMITTEE ON HEALTH AND ENVIRONMENT
MAY 11, 2000
Good morning. I am David Satcher, Assistant Secretary for Health, Department of Health and Human Services (HHS), and Surgeon General of the United States. I thank you, Mr. Chairman and members of the Committee, for your invitation to testify at this important hearing on how to improve the quality of health care for minorities and H.R. 3250, The Health Care Fairness Act of 1999. With me today are technical experts from the HHS agencies involved in ensuring the quality of health care for all Americans. They are: Kermit C. Smith, D.O., the Chief Medical Officer of the Indian Health Service; and John Ruffin, Ph.D., Associate Director Office of Research on Minority Health at the National Institutes of Health.
Let me say that the topic of your hearing could not be more appropriate, for indeed, as we look at the state of minority health in America we are really looking into the future of our nationís health.
BACKGROUND ON MINORITY HEALTH
In the 1985 Report of the Secretaryís Task Force on Black and Minority Health, Secretary Margaret M. Heckler wrote these words, " In January 1984 Ė ten months after becoming Secretary of Health and Human ServicesĖ I sent Health, United States, 1983 to the Congress. It was the annual report of the health status of the American people. That reportĖ like it predecessorsĖ documented significant progress: Americans were living longer, infant mortality had continued to declineĖ the overall American health picture showed almost uniform improvement. But, and that "but" signaled a sad and significant fact, there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nationís population as a whole. That disparity has existed ever since accurate federal record keeping beganĖ more than a generation ago. And although our health charts do itemize steady gains in the health of minority Americans, the stubborn disparity remainedĖ an affront both to our ideals and to the ongoing genius of American medicine. The report is comprehensive. Its analysis is thoughtful. Its thrust is masterful. It sets the framework for meeting the challenge-- for improving the health of minorities. It can-- it should-- mark the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health."
It is now the year 2000.
Compelling evidence that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations demands national attention. Indeed, despite notable progress in the overall health of the Nation, there are continuing disparities in the burden of illness and death experienced by African Americans, Hispanics, American Indians, Alaska Natives, and Asian Pacific Islanders, compared to the U.S. population as a whole. Current information about the biologic and genetic characteristics of racial and ethnic groups does not explain the health disparities experienced by these groups compared with the white, non-Hispanic population in the
United States. These disparities are believed to be the result of the complex interaction between genetic variations, environmental factors, economics, specific health behaviors, and discrimination.
Even though the Nationís infant mortality rate is down, the infant mortality rate among African Americans is still more than double that of white citizens. Heart disease death rates are more than 40 percent higher for African Americans than for whites. The death rate for all cancers is 30 percent higher for African Americans than for whites; for prostate cancer, it is more than double that for whites. African American women have a higher death rate from breast cancer despite having a mammography screening rate that is higher than for white women. The death rate from HIV/AIDS for African Americans is more than seven times that for whites; the rate of homicide is six times that for whites.
Hispanics living in the United States are almost twice as likely to die from diabetes as are non-Hispanic whites. Although constituting only 11 percent of the total population in 1996, Hispanics accounted for 20 percent of the new cases of tuberculosis, and have higher rates of hypertension and obesity than non-Hispanic whites. There are differences among Hispanic populations as well. For example, whereas the rate of low-birth-rate weight infants is lower for the total Hispanic population compared to whites, Puerto Ricans have a low-birth-weight rate that is 50 percent higher than that for whites.
American Indians and Alaska Natives have an infant mortality rate almost double that of whites. The rate of diabetes for this population group is more than twice that for whites. The Pima of Arizona have one of the highest rates of diabetes in the world. American Indians living in North and South Dakota have an average life expectancy that is 11 years less than that for the rest of the U.S. population. Overall, the life expectancy for American Indians and Alaska Native is 71 years of age- nearly five years less than the U.S. Races populations.
Asian and Pacific Islanders, on average, have indicators of being one of the healthiest population groups in the United States. However, there is great diversity within this population group, and health disparities for some specific groups are quite marked. Vietnamese women suffer from cervical cancer at nearly five times the rate of white women. New cases of hepatitis and tuberculosis are also higher in Asians and Pacific Islanders living in the United States than in whites.
The Indian Health Service (IHS) and Native American Tribes have made much progress improving the American Indian and Alaska Native health status over the years. Infant mortality rates, maternal death rates, morbidity and mortality from infectious diseases have all decreased dramatically over the past 40 years. However, during the last five years, this progress has stalled and indeed regressing in some areas. American Indian infant mortality is beginning to increase in some communities. During 1992-1994, the infant mortality rate for the IHS Phoenix Regional Area was 9.4 deaths per 1,000 live births. The rate increased to 9.7 from 1994-1996. In the IHS
Nashville Regional Area, the rate increased from 11.6 per 1,000 live births to 11.7 over the same time frame.
Behavior-related mortality rates for the American Indian population residing in the IHS regional service areas are rising. For example, age-adjusted mortality rates for AI/ANs due to alcoholism, suicide, and homicide during 1992-1994 were 45.5, 19.2, and 15.1 deaths per 100,000 persons, respectively. The 1994-96 data indicate these numbers increased to 48.7 deaths per 100,000 for alcoholism, 19.3 for suicide, and 15.3 for homicide. During this time period, the age-adjusted mortality rate for AI/AN for HIV infections rose 59 percent, and for diabetes mortality, an increase of 13 percent. Increases in age-adjusted mortality rates are also noted for this population in malignant neoplasms and cerebrovascular disease.
Slight improvement has been made between 1992-1994 and 1994-1996 in age-adjusted mortality rates for AI/ANs due to Tuberculosis (a rate of 2.3 improved to a rate of l.9) and heart disease (a rate of 157.6 improved to a rate of 156.0). However, increases in age-adjusted mortality rates were experienced for AI/ANs deaths due to malignant neoplasms (a rate of 112.2 during 1992-1994 increased to a rate of 116.6 during 1994-1996) and for AI/ANs deaths due to cerebrovascular diseases (a rate of 27.8 during 1992-1994 increased to a rate of 30.5 during 1994-1996). The bottom line figure of life expectancy at birth for American Indian and Alaska Native population in the IHS regional service delivery areas remained exactly the same between the 3-year period 1992-1994 and 1994-1996, 71 years.
HHS INITIATIVE TO ELIMINATE DISPARITIES IN HEALTH
The demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status. Groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population; therefore, the future health of America as a whole will be influenced substantially by our success in improving the health status of our racial and ethnic minorities.
In June 1997, President Clinton introduced to the country the concept of One America in the Twenty-first Century: The Presidentís Initiative on Race. He appointed a national advisory board led by John Hope Franklin, and in their September 1998 report to the President, "One America in the 21st Century: Forging a New Future," they included their observations on what they saw and heard about race and its impact upon communities throughout the country. The Board report also offers recommendations on specific steps that should be taken to eliminate racial disparities experienced by people of color.
Additionally, the President asked each cabinet head to develop some strategy supporting the Race Initiative. In the Department of Health and Human Services, we adopted the commitment to eliminate disparities in health on the basis of race and ethnicity by the year 2010. The President announced this unprecedented initiative from the White House in February 1998. We focus on six key areas: infant mortality, breast and cervical cancer screening and management, cardiovascular disease risk factor reduction, diabetes complications, adult and childhood immunizations, and HIV infections and AIDS. These six health areas were selected for emphasis for they reflect areas of disparity that are known to affect multiple racial and ethnic minority groups at all life stages and are areas over which we could have direct impact.
This Initiative marks the first time in the history of our government that we have made the commitment to eliminate, not just reduce, the health disparities between majority and minority populations. Additionally, the Initiative will parallel the second goal of Healthy People 2010, the
Nationís disease prevention, health promotion agenda for the first decade of the 21st century. The other goal is to increase the quality and years of healthy life.
The Initiative is led by the Office of Public Health and Science (OPHS) and the responsibility for overall guidance within HHS is the Public Health Council (PHC).
Beginning shortly after the Presidentís announcement, working groups comprised of experts from the agencies within HHS met to discuss the status of HHS programs and policies in the six health focus areas and the data issues relevant to the Initiative. These working groups have generated full length reports that review the epidemiology of the six focus areas and examine a range of strategies for effective interventions for prevention and treatment. The reports offer recommendations for future research, policies, and program investments that would lead to the elimination of health disparities.
One of the most visible components of the HHS Initiative is the Racial and Ethnic Approaches to Community Health 2010 program (REACH 2010). REACH 2010 is intended to help communities mobilize and organize their resources in support of effective and sustainable programs that will eliminate health disparities. In FY 1999, Congress appropriated $10 million dollars to the Centers for Disease Control and Prevention (CDC) to administer the program. The first year of REACH demonstrations was designed as a planning year to solidify the multi-
agency, community oriented collaboration required of the applicants. Subsequent
years will involve implementation of the interventions to address one or more
of the six clinical focus areas within a well- defined population.
CDC used this appropriation to fund 32 community coalitions and three additional community coalitions were funded by the California Endowment to participate in REACH 2010. The populations targeted include African-American, American Indian, Alaska Native, Hispanic American, Asian American, and Pacific Islander. Of the awards, five were for infant mortality, five for breast and cervical cancer screening and management, four for immunizations, twelve for diabetes complications prevention, twelve for cardiovascular disease risk factor reduction, and two for HIV infection and AIDS. These awards were spread over 18 states and 22 cities.
The FY 2000 appropriation of $30 million will be used to implementation of the community derived strategies and to enlist new community coalitions in the effort to eliminate disparities.
The Office of Civil Rights (OCR) has played a critical role in the departmentís Initiative to Eliminate Racial and Ethnic Disparities. Through enforcement, education and outreach, OCR has raised public awareness of the role of discrimination as one explanatory factor in racial and ethnic disparities. Recent OCR cases illustrate the discrimination regrettably is alive and well in the health care setting.
- OCR reached a settlement with a national home health agency that had engaged in medical redlining, that is, it refused to serve a predominantly minority area of New Haven, Connecticut;
- OCR reached an agreement with a national pharmacy chain that had repeatedly failed to fill the prescription of an African-American Medicaid recipient in Texas;
- OCR reached a settlement with a hospital in South Carolina that had a policy in effect of not giving epidurals to women who did not speak English; and
- OCR reached a settlement with a hospital in Philadelphia whose lack of an effective policy for treating patients who do not speak English created serious problems for a pregnant woman who needed emergency care.
OCRís enforcement, coupled with recent research documenting the potential role of racial bias in explaining physician decision-making, illustrate that eliminating racial and ethnic disparities is
both a civil rights and a public health challenge. If we ignore the former and focus solely on the latter, we will not be fully successful.
Addressing the challenge of health improvement is a shared responsibility that requires the active participation and leadership of the Federal Government, States, local governments, policymakers, health care providers, professionals, business executives, educators, community leaders, and the American public itself.
A national partnership is needed to develop a balanced community health system that promotes healthy lifestyles and behaviors, and in challenges a health care delivery system that allows for unequal outcomes on the basis of race and ethnicity. The task of HHS is to provide leadership through conducting innovative and balanced research, expanding and improving programs to purchase or deliver quality health services, developing programs to reduce poverty and provide children with safe and healthy environment, and by expanding prevention efforts. Currently, our activities include, but are not limited to:
- In October 1997, the Secretary issued the first Federal agency policy requiring
the inclusion of racial and ethnic data in all of its data systems, with very
few exceptions. The inclusion policy also required compliance with the Federal
standards for racial and ethnic data.
- In February 2000, the HHS Data Councilís Working Group on Racial and Ethnic
Data and the Data Working Group of the HHS Initiative to Eliminate Racial
and Ethnic Disparities in Health presented their joint report on "Improving
the Collection and Use of Racial and Ethnic Data in HHS" to the Data
Council. This report builds upon the numerous recommendations developed in
the past and presents a long term agenda for improving the collection and
use of racial and ethnic data across the Department and its agencies. This
report sets the stage for the National Academy of Sciences report which is
called for in the Health Care Fairness Act under discussion today.
- The Health Care Financing Administration (HCFA) now requires each state
Peer Review Organization (PRO) to include a focus on eliminating racial and
ethnic disparities in health. PROs had previously been required to focus on
improving quality of care in several other key clinical areas closely related
to the Initiative.
- The Agency for Healthcare Research and Quality (AHRQ) plans over the next
five years to establish up to four "centers of excellence" that
will identify practical tools and strategies to eliminate racial and ethnic
disparities in the health care system. The research conducted by these centers
will go beyond documenting disparities by putting a new emphasis on understanding
their underlying causes and developing strategies to eliminate them.
- In February 2000, an important working conference, "Diversity and Communication
in Health Care: Addressing Race, Ethnicity, Language, and Social Class in
Health Care Disparities" was sponsored by the Office of Minority Health,
the Health Resources Services Administration (HRSA), AHRQ, the Commonwealth
Fund, and the Sergei Zlingoff Fund for Medical Education and Research. The
purpose of the conference was to determine the state-of-the-art for improving
provider-patient communication, to define its adequacy to increase effectiveness
of health care for racial and ethnic minorities, and to develop a work plan
to provide needed modifications. A larger conference is called for in the
Health Care Fairness Act.
- In addition to the work discussed earlier, the Office of Civil Rights is focusing on a program of dialogue and education of health care providers and patients to increase awareness of civil rights responsibilities. For instance, in New York City, OCR has convened a series of meeting with all stakeholders- providers, advocates, faith communities, foundations, medical societies, hospital associations, and others in an effort to develop a greater understanding of the root causes of racial and ethnic disparities, as well as a blueprint for eliminating disparities. This dialogue has been extremely productive, and talk has led to constructive action. At the same time OCR has begun to look at data pertaining to hospitals to determine why some high tech medical procedures do not appear to be performed on minorities at the same rate as non-minorities.
- HRSA has launched a campaign for 100 percent access, 0 percent disparities by the year 2010. As part of its mission to provide quality comprehensive health care to under served and vulnerable populations, HRSA hopes to build and sustain healthier communities by empowering communities to identify and develop solutions tailored to their needs. Currently, 23 states and over 100 communities are engaged in the campaign. Additionally, HRSA has funded 10 communities across the country to address significant disparities in perinatal health indicators. These communities demonstrated significant infant mortality and morbidity rates, had an existing consortia of stakeholders with infant mortality reduction experience, and developed a feasible plan to reduce barriers, improve systems of care, and eliminate disparities.
- As required in the re-authorization of the Office of Minority Health, HHS is establishing its first Advisory Committee on Minority Health. We understand that this advisory committee could serve the role of that called for in the Health Care Fairness Act to provide advice to the Secretary on matters related to the development, implementation, and evaluation of graduate and continuing education curricula for health care professionals to decrease the disparities in health care and health outcomes.
- The National Institutes of Health (NIH) remains committed to conducting research on the diagnosis, treatment, and prevention of diseases resulting in health disparities, including AIDS, cancer, diabetes and heart disease. We recognize that these efforts would be enhanced by a central organization that coordinates and reviews the health disparity research being conducted by the NIHís various Institutes and Centers. Therefore, NIH has established a Working Group on Health Disparities that is currently developing a Strategic Plan to expand training programs for minority researchers, set priorities and synchronize multi-disciplinary research. The Strategic Plan will be reviewed by the Office for Research on Minority Health and its public Advisory Committee. The unprecedented level of coordination and input from the public, including those most affected by health disparities, and the prominent role played the Office for Research on Minority Health, should result in measurable improvements.
- The Indian Health Service, Department of Health and Human Services, and the Administration are working with Indian Tribes to address the disparity in health status among American Indian and Alaska Native people. During the past 3 years the Indian Tribes have identified alcoholism/substance abuse, diabetes, cancer, heart disease, infectious disease, maternal and child health, mental health, injuries and domestic/community violence as the top health problems that must be addressed by the IHS budget requests. Local IHS/Tribal/Urban(ITU) health priorities dovetail with the Presidentís Race Initiative on Health Disparity focus and underpin the Indian health budget priorities set by the Indian Tribes and the Administration in the past 2 years.
- The IHS, tribes and urban health programs have demonstrated the ability to improve the health status of American Indian and Alaska Native people. Improving essential access to health care in order to address health disparities has been a top priority for the I/T/Uís annual budget and Government Performance and Results Act performance plan initiatives. The first annual performance report, which was submitted for FY 1999, provides a base performance level for the health interventions/measures that will ultimately lead to improved outcomes in health status. Indian Tribes are becoming increasingly involved in developing the performance targets. Joint Federal-Tribal efforts are directed toward achieving these targets as a means of demonstrating the effectiveness of the I/T/U programs to make a difference in the disparities that exists between the health of American Indian/Alaska Native people and the rest of the Unites States.
PUBLIC/PRIVATE PARTNERSHIPS TO IMPROVE MINORITY HEALTH
As the Nation enters a new millennium, an unprecedented opportunity exists to influence and effect health in a way that is fundamentally fair, and more inclusive of all Americans. HHS has "stepped to the plate" to eliminate disparities in health and has created an environment where private foundations and endowments are engaging their colleagues to eliminate disparities in health. For example:
- HHS and Grantmakers in Health (GIH), an educational organization that works with foundations and corporate giving programs to improve the nationís health, cosponsored a national leadership conference in September 1998, to discuss strategies for developing and strengthening partnership focusing on eliminating racial and ethnic disparities in health by 2010. Attending the conference were approximately 250 key public policy makers, industry and community leaders, including individuals representing foundations, community-based organizations, national organizations with expertise in key health areas and with a history of serving racial and ethnic groups, providers, insurance companies and managed care plans, the media, business, faith-based organizations, and consumers.
- The California Endowment has initiated a Program in Multi-cultural health aimed at eliminating health disparities and through collaboration with the CDC Foundation, funded three additional REACH 2010 projects in California.
- The Robert Wood Johnson Foundationís Investigators Award in Health Policy Research Programs is seeking to improve understanding of the social determinants of health.
- The Commonwealth Fund cosponsored a meeting with managed care organizations on data collection, quality of care measurement, and access to health care. As a result, efforts are being made to educate health plans that the Federal government does not prohibit the collection of racial and ethnic data.
- The Henry J. Kaiser Family Foundation hosted a conference on ĎRace, Ethnicity, and Medial Care: Improving Access in a Diverse Society." This conference sought to understand the reasons for disparities in access to health and health status, and develop more effective efforts to address them. The Foundation is developing a set of "leading health indicators" by which to measure the progress made toward the elimination of disparities.
- The National Policy Association, the Association of Health Services Research, and several HHS agencies cosponsored a conference in April 2000 on "Income Inequality, Socioeconomic Status and Health: Exploring the Interrelationships." The purpose was to bring together business and labor leaders and experts in health and social policy to address critical questions about health and health disparities.
- OCR has worked closely with the United Hospital Fund, the Greater New York Hospital Associate, and the New York Task Force on Immigrant Health to develop a pilot program that used state of the art technology and trained interpreters to enable health care providers to communicate more effectively with persons who are limited English proficient.
- During the 1999-2000 legislative sessions for the States, eighteen states had pending legislation or executive orders that related to the elimination of health disparities or improving the quality of care to minorities. We are working to identify the status of these bills now that most sessions have ended.
- On April 24, 2000, HHS and the American Public Health Association announced a partnership to eliminate racial and ethnic health disparities. The partnership includes a three phase plan to develop a charge or "blueprint" of guidelines for our collaboration, develop a detailed, comprehensive national plan, and thirdly, the implementation of the plan by 2002.
ROLE OF THE HEALTH CARE FAIRNESS ACT OF 1999 IN IMPROVING MINORITY HEALTH
We thank you for your support of the HHS Initiative to Eliminate Racial and Ethnic Disparities in Health, and its parallel emphasis within Healthy People 2010. The proposed Health Care Fairness Act of 1999 (H.R. 3250) addresses several of the key elements the Department has identified as essential to a comprehensive approach towards eliminating disparities:
- development of a balanced and comprehensive research agenda that addresses the unequal burden of morbidity and mortality in racial and ethnic minorities;
- supporting efforts to improve the quality and outcomes of health care services and addressing the social determinants of health, including but not limited to, access to health care;
- strengthening the data collection infrastructure of HHS;
- recognition of the important role of the Office for Civil Rights;
- support for graduate health care education curriculum development, continuing medical education efforts to reduce disparity in health and health outcomes, and increasing the knowledge base with respect to cultural competency.
We particularly appreciate acknowledgment of the importance of research into the behavioral and social factors underlying health disparities, and support programs which increase educational attainment and employment opportunities.
The section of the Health Care Fairness Act on the Office for Civil Rights is supportive of efforts underway to include the Office in development of health policy throughout HHS that address civil rights observance, program evaluation, and quality assessment.
Mr. Chairman, and members of this committee, as a physician and scientist, administrator and educator, and one charged with the task of leading the effort to challenge a health care system that allows for an unequal burden of morbidity and mortality among our racial and ethnic groups, I am reminded of how the National Institutes of Health explain how research and science work.
It is said that "science" comes from the Latin scientia meaning "known things," scientists and the practice of science exist because of what we do not know. The aim of science is to move what we do not know into the realm of known things and then, with a greater store of knowledge, begin again, as if advancing to a new frontier.
The elimination of disparities is an achievable goal that requires we bring all our forces to bear--a balanced community health system, a comprehensive research agenda that addresses the unequal burden of morbidity and mortality in racial and ethnic minorities, training a multi-cultural workforce that is sensitive to the culture of its colleagues, data collection that reflects the inhabitants of this country, and one set of quality health care delivery goals for all. As we continue our work to improve the lives of our fellow Americans, let me leave you with the
premise upon which the U.S. Public Health Service was founded in 1798, is ... " to the extent we care for those most vulnerable among us, we do most to protect the health of the nation."
Thank you for the opportunity to share some of the Departmentís activities. We appreciate your support and look forward to continuing our partnership to improve our health care system.
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