This diary will introduce our health articles found on Race-Talk.
Beyond health care reform: Write a check for Indian health
DEC 14, 2009 - By Mark Trahant,Journalist and Kaiser Media Fellow
I started my exploration of health care reform in July.
"The federal government accepts a double standard: Any discussion about rationing – or government care – is off the table unless you’re a member of an American Indian tribe or Alaskan Native community with a sort of pre-paid insurance program (many treaties, executive orders and laws were specific in making American Indian health care a United States’ obligation)," I wrote back then.
Six months later – or half way into this project – I am struck by how Indian Country is both a part of the health care debate and yet absent from its larger discussion.
We’re part of the conversation every time critics blast the Indian Health Service as a failure of government. We’re also included in the larger reform measure – the Indian Health Care Improvement Act – was added to the larger bill. That’s a good thing because this bill (unlike the original) has been awfully difficult to move through the Congress.
But we’re absent from the conversation because neither the Congress nor the Executive Branch has articulated what lessons can be learned from the history and experience of the Indian health system as it applies to the larger issue of health reform. It’s particularly frustrating to watch the politicians who are quick to point out the weaknesses of that system even though they have never proposed adequate funding or the dreaded idea of rationing.
Consider how the money question goes beyond Indian Country: If the federal government can’t deliver on this one, relatively small promise, how is it going to make good on remaking one-sixth of the economy in a few thousand pages of legislation? Indeed, the history of federal appropriations – as well as the operation of a health care delivery system – ought to be applied to design of a larger health care system. That’s the ideal, anyway.
But there is another subject I want to write about during my next six months of my project: Ideas for strengthening the Indian health system regardless of the larger reform. Yes, more money is needed. And, perhaps, health care reform will deliver on at least some part of the federal government’s promise.
But that’s not enough. The Indian Health system must rapidly adapt to a new order of things. At the top of that list has to be a 21st century business model, one that recognizes the limitations of the federal government.
Sure, this will mean better third-party billing of private insurance plans, Medicaid and more. But even that will not be enough. There also ought to be a philanthropic component.
It’s time to invent a well-endowed national Indian health foundation, as well as regional and tribal foundations, to fund specific patient needs or programs that cannot secure government funding. The money could come from foundations, wealthy people, tribes, really, anyone who has compassion for people who need urgent health care they cannot afford. While the recession has taken its toll on the nonprofit sector, Americans remain committed to giving.
This is the flip side of rationing; it’s an incredible opportunity to do something to improve the system without Congress. Some $350 billion is raised in this country for charities and as much as half goes to health care, notably hospitals. What if Indian Country had a non-profit fundraising goal of 1 percent of all health care giving? It’s a big number.
Actually the question is this: If the infrastructure were there, who wouldn’t want to give? Every story published about the failures of the system or Indian health disparity is just one more reason to write a check. An idea for the new year – Happy 2010.
Between the lines: kids of color; mental health care
DEC 14, 2009 - By Nisha Agarwal,Director of the Health Justice Program at New York Lawyers for the Public Interest
This weekend the New York Times reported on a new study which finds that kids on Medicaid are four times more likely to be prescribed antipsychotic drugs than their privately insured counterparts, and often for conditions for which the drugs are not FDA approved such as A.D.H.D. and conduct disorders. These drugs may not only have significant psychological impacts on the children who take them, but they also cause long-term physical harm. This is terrible no matter what, of course, but let us be very clear about what we are talking about here. In places like New York City, where African-Americans and Latinos are 3.5 times more likely to be on Medicaid than whites, the kids we are talking about are black and brown.
sjigo_h28eThe children who are being systematically over-medicated and denied high quality mental and behavioral health services are disproportionately young people of color. What we are talking about, then, is race even if all but the most oblique reference to it has been scrubbed from the lines of the mainstream media coverage.
Let us also be clear about how this may be happening. The Times piece implies that certain problems with the Medicaid program, such as low reimbursement rates for therapy, contribute to the over-medication of children by creating incentives for doctors to prescribe antipsychotics or by reducing the availability of psychiatrists who accept Medicaid, thus funneling low-income kids to non-specialists who are more likely to provide treatment through drugs. This may very well be true, but let us unpack these dynamics as well from the racial justice tip.
In New York City, where I work, there are large, well-respected institutions providing high quality mental health services for children that refuse to accept Medicaid patients ostensibly because they don’t pay that well. This can be viewed as a rational dollars-and-cents reaction to an inadequate Medicaid system, but when you consider the close relationship between insurance and race, it starts to look like a modern version of Whites Only. Such policies become all the more difficult to swallow when you compare them to the approach of some community-based health care providers that also exist in the city and manage to make mental health services available effectively and equitably.
The directors of clinical services at these community health centers will tell you about how they’ve figured out their administrative and billing infrastructure so they can work around some of Medicaid’s challenges to provide high quality mental health care to all patients, regardless of their insurance. Providers like these fight alongside consumer advocates to preserve Medicaid and make it better because they recognize how critical it is to the lives of their patients. They don’t retreat from the system or take shortcuts, hoping that poor kids of color and their mental health problems will just go somewhere else. Indeed, they bear responsibility for their colleagues at other institutions, who disguise their discrimination in the form of a "rational" economic calculus.
You can expect to hear more about the doping of America’s children in the coming year, as more studies are released and blue-ribbon policy panels convened to address the problem. What you probably won’t see are many efforts to write race into the story or the solution. That is our job as racial justice advocates: to read between the lines and move in from the margins.
###
Nisha Agarwal is the Director of the Health Justice Program at New York Lawyers for the Public Interest, where she began her legal career as a Skadden Public Interest Fellow. Ms. Agarwal's work at NYLPI focuses on bringing a racial justice and immigrant rights perspective to health care advocacy. In collaboration with community-based organizations and coalitions across New York City, Ms. Agarwal is working on campaigns on language rights in pharmacies, racial discrimination in hospitals, medical deportation, and the closure of community hospitals and clinics in medically under-served areas. Nisha is also active in the South Asian Bar Association of New York, where she serves as Vice President for Public Interest, and is the co-founder of the Harvard Law School Summer Theory Institute for public interest law students. Ms. Agarwal earned her BA, summa cum laude, from Harvard College in 2000 and received a British Marshall Scholarship for graduate studies at Oxford University. She received her JD from Harvard Law School in 2006.
Challenging the master narratives about government health care
DEC 14, 2009 By Mark Trahant,Journalist and Kaiser Media Fellow
There are two master narratives about the Indian Health Service.
First, everyone knows the Indian health system needs more money. Everyone, it seems, except the collective members of Congress who, when they write budgets, can’t seem to appropriate at least as much money as they do for the U.S. Bureau of Prisons.
And, second, critics say the Indian Health Service represents the failure of government-run care with complaints ranging from rationing to mismanagement of government funds. Just last week Sen. Tom Coburn, R-Oklahoma, repeated this narrative in his attack against the Senate’s health care reform bill. He again called the IHS "a failure."
These two narratives stick because the truth is far more complicated. It’s hard to communicate a "yes, but" message in a political context. Yes, the IHS does ration care – but that’s because it has only so much money in its budget. Yes, the IHS isn’t perfect with its spending (or insurance billing operations), but is that also a reflection of its limited budget? We really won’t know the answers unless the agency gets adequate funding.
There is another story that deserves at least the same attention as the first two themes: The really remarkable efforts underway to improve quality for American Indian and Alaskan Native patients.
A partnership began three years ago with the IHS and the Institute for Health care Improvement focused on chronic diseases. The project is now called Improving Patient Care, or IPC, and is designed to show measurable improvements in preventive care, experience of care, managing chronic conditions, while maintaining financial viability.
In plain language the goal of IPC is to make it easier for patients to see a doctor or nurse and then to spend less time in the waiting room (without spending too much money in the process). This is the ultimate initiative for doing more with less.
Dr. Charles "Ty" Reidhead, currently a fellow with the Institute for Health care Improvement in Boston as well as National Chief Clinical Consultant in Internal Medicine and chair of the Chronic Care Initiative for the IHS, says the exciting thing about the IPC is that it is a tool to help "people who are already wanting to do better."
"We learned pretty early on from the teams that it wasn’t just about chronic conditions," Reidhead said. There was a solid track record of success from the IHS diabetes program, "so the idea was to do better at all the other conditions."
The problem was if you pick any one condition, whether it’s cardiovascular or depression, a single focus might not be enough.
"We were worried that we wouldn’t change the system enough, we’d get better diabetes or depression care," said Reidhead. "Instead what we tried to do to look at patient care to meet their needs, no matter what they came in with."
One innovation to improve care was a standard bundle of patient tests, flagging early warning for alcohol misuse, depression, domestic violence, tobacco use, blood pressure and obesity.
Nearly 40 units in the Indian health system are part of the IPC pilot. A key element of the initiative is transparency. Results are measured and become learning tools that are shared across units in the program.
One of the reasons why the Indian health system is ahead of the rest or the country is the word "system." If nothing else this is what needs to be part of the larger discourse about health care. When a patient is discharged from a hospital, that system ends its service. There is no more. But that’s not true for health providers run by the IHS, tribes or urban organizations. They provide care for a "population." The patient remains in the system even after being released from a hospital.
Why does a systemic approach matter? Because treating chronic diseases represents three-out-of four health care dollars. The goal of a low cost, high quality system is the only sustainable model going forward. And that is a story that must be told.
###
Mark Trahant is a writer, teacher and a "Twitter poet." He is a 2009-2010 Kaiser Media Fellow and will be writing about health care reform with the focus of learning from programs the government already operates, such as the Indian Health Service. Mark writes daily "news poems" on Twitter, four line rhymes based on current news events under the handle, "NewsRimes4lines." He is the former editor of the editorial page for the Seattle Post-Intelligencer where he chaired the daily editorial board, directed a staff of writers, editors and a cartoonist. He has been chairman and chief executive officer at the Robert C. Maynard Institute for Journalism Education. The Oakland, Calif.-based nonprofit is the country's premier institute for providing advanced training and services nationally to help news media reflect diversity in content, staffing and business operations. Trahant is a member of Idaho's Shoshone-Bannock Tribe and former president of the Native American Journalists Association. He also serves as a trustee of The Freedom Forum, a foundation that promotes free press, free speech and free spirit based in Arlington, Virginia. He is also a Trustee of the Diversity Institute, an affiliate of the Freedom Forum. Trahant was a juror for the Pulitzer Prize in 2004 and 2005.
A New Lesson from the Old "Tuskegee" Study
DEC 3, 2009 By Susan M. Reverby, McLean Professor in the History of Ideas and Women’s and Gender Studies at Wellesley College
"Don’t take the swine flu vaccine. Remember the Tuskegee Experiment Syphilis Vaccine," a recent post on Twitter warns. The message is simple: "Tuskegee," America’s notorious medical research study, is still considered as our own equivalent to Nazi experimentation that links state power to scientific fervor. Nearly forty years after the study ended, the name "Tuskegee" evokes fears of the dangers of government involvement in medical care. But as Congress debates how to provide health coverage for everyone and fear of the swine flu vaccine runs rampant, there is a different critical lesson to take from the infamous medical research project which targeted poor rural African American men and ran unabated for decades.
From 1932 to 1972, the U.S. Public Health Service (PHS) conducted a study on "untreated syphilis in the male Negro" in Macon County, Alabama in and around the city of Tuskegee. 439 African American men with late stage syphilis were selected as research subjects, and 185 without the disease became the study’s control group. A mostly sexually transmitted disease, syphilis left untreated can cause fatal heart and neurological problems. The men thought of themselves as patients obtaining needed medical care for what was known as "bad blood" from the government’s doctors. The PHS physicians never told these men they were actually research subjects being followed in a "no treatment" study.
Instead, the researchers explained that the aspirins, tonics, and diagnostic spinal taps given were "free treatment." In a county with only 16 doctors whose prices the men could rarely afford, a government program of free care enticed them. The study’s nurse kept visiting the men’s homes and helping them to get medical care for other ills. The study’s subjects and controls were also promised money for decent burials in exchange for the use of their bodies for autopsy after their deaths.
The study was not kept secret. Medical articles charting its progress appeared over the decades, while several health professionals questioned the study’s ethics. In 1972 the research experiment came to an end in a storm of media coverage that brought in federal investigators, a Senate hearing, and a subsequent lawsuit against the PHS, the state of Alabama, and many of the doctors involved.
In "Tuskegee’s" wake, major changes in federal rules governing medical research were established, including written informed consent and the creation of institutional review boards to oversee human subject research. The study also created another legacy—it became the metaphor for the distrust of scientific research, the risks of government provision of medical care, and the exploitation of poor patients.
Rumors and myths about what happened continue to circulate in whispers, blogs and media coverage. Most egregious in the face of the need for H1N1 vaccine is the erroneous claim that the government’s doctors intentionally infected the men with syphilis. But no "Tuskegee experiment syphilis vaccine" was ever created; no shots of the bacteria that cause syphilis were put into the men’s veins.
As the Obama administration takes on the huge task of reforming how we organize and pay for health care for all Americans and we line up for our shots, "Tuskegee" can offer another perhaps less obvious, if ironic, lesson. These men living in rural Alabama came forward for treatment not because they were uneducated and easily duped by their government, but because they needed health care for themselves and their families. They, as with increasing numbers of Americans, had no real access to the medical care they required, could not pay for what was available, and had to find it where possible.
Perhaps as the debate over health care reform winds its way through the Congress, a new post on Twitter should read: "Don’t forget the ‘Tuskegee’ syphilis study. Everyone deserves the right to affordable health care and this is what our government should and must provide."
###
Susan M. Reverby is the McLean Professor in the History of Ideas and Women’s and Gender Studies at Wellesley College and is the author of Examining Tuskegee: The Infamous Syphilis Study and its Legacy.
Will the Senate forget to discuss health care AND race?
DEC. 2, 2009 - By Cliff Albright, Political Strategist
As the battle over health care reform hits the Senate floor for debate, I’m wondering how long it’s going to take for the issue of race to pop up.
Oh, it won’t show itself as blatantly as it has at town hall meetings and conservative rallies. I hardly expect one of the Senators to set up an easel with one of those pictures of President Obama dressed as a witch doctor. No, it will be far more subtle than that. Instead of shouted, race is likely to be whispered and alluded to in the form of comments about "those people" who take advantage of big government and who make it harder for the good, tax paying Americans. You know "those people"—they’re the same ones who hang out with the welfare queens, standing on the corner eating candy bars that they purchased with their fraudulently obtained food stamps.
Possibly, race may show up in a slightly more direct way, perhaps in relationship to health coverage for immigrants. Remember, that’s the same issue that propelled Rep. Joe Wilson into stardom after he called the president a liar.
Honestly, I’m not exactly sure how race will show up, but I promise you, it will. The only question is whether or not we’ll have the courage to actually talk about it. Judging from the reaction to Jimmy Carter’s comments—comments that correctly pointed out the role of race in the vitriolic opposition to health care reform—my guess is we’ll be neither willing nor able to discuss the issue.
Of course, I’ve been saying Carter was correct ever since he made the comments, but until recently I haven’t had any actual data to support that belief, other than the common sense that God gave me. But thanks to professors Marc J. Hetherington and Jonathan D. Weiler, that’s no longer the case. The two professors recently analyzed a survey which documented people’s attitudes towards health care reform as well as their attitudes towards Black people. According to their Washington Post article:
We find an extraordinarily strong correlation between racial resentment of blacks and opposition to health care reform. Among whites with above average racial resentment, only 19 percent favored fundamental health care reforms and 57 percent favored the present system. Among those who have below average racial resentment, more than twice as many (45 percent) favored government run health care and less than half as many (25 percent) favored the status quo.
Interestingly, the professors state that there was no such racial correlation during President Clinton’s health care reform efforts.
I wonder why.
Anyway, while some of the racial resentment directed towards health care reform stems from attitudes about President Obama, I have no doubt that some of the resentment is more ambiguous. Instead of being focused on one person, the racial attitudes have more to do with perceptions of who will benefit from health care reform.
Research shows that when asked about the racial makeup of assistance programs, most people assume far higher percentages of people of color than is actually the case, and these perceptions impact political support. In short, when White people that think "others" will benefit disproportionately from government programs, many of them simply aren’t as likely to support those programs.
Well, right now I don’t know who will end up benefiting the most from health care reform, but it’s pretty clear who needs it the most, and that’s people of color.
One government report on Health Disparities documents how people of color have higher rates of disease but reduced access to care. Another report, Unequal Lives, produced by the coalition Health Care for America Now, also documents the differences in insurance coverage. However, the most troubling findings involve outright discrimination; the findings apply even when people of color have similar coverage and income as Whites. The report shows that even in those scenarios, people of color still have less access to standard tests, less access to life-extending high-tech procedures and a higher likelihood of undesirable (and avoidable) treatments (such as amputations).
Now, having presented these statistics, let me be clear, my point is NOT that it’s okay for White people to be without health care. I happen to believe that health care is a human right and that in the richest country in the world, no one should be without proper health care. I despise all poverty, and I agree with Dr. Martin Luther King that at some point we need to stop feeling good about giving beggars some change and start changing structures that SYSTEMATICALLY produce beggars.
Some say that such change requires universal solutions, such as social security, FHA loans and the G.I. bill. But we often forget that these universal solutions were far from race neutral, they actually broadened the gap between Black and White. Similarly, generic health care reform that fails to address the racial disparities listed above could very well have the same effect.
With that in mind, the Congressional Black Caucus, the Hispanic Congressional Caucus and the Asian Pacific American Caucus worked hard to make sure that the House bill included programs and funding to address the racial disparities. According to an article at politico.com, the House bill "calls for a $12 billion increase over the next five years in funding for community health centers." The bill also includes funding for community health workers, school-based health care clinics and cultural/language training for health care providers.
While the House bill is a step in the right direction, the question remains whether the targeted funding will exist in the Senate version. More importantly, will there even be a Senate version? If these questions are to be answered in the affirmative, then Black, Latino and other marginalized communities are going to have to step up our involvement.
A coalition of organizations, including the NAACP National Voter Fund, the National Council of La Raza, PowerPAC.org and others, has come together to sponsor an ad campaign aimed at mobilizing communities of color. The ads are focused on states with large populations of people of color AND which have Senators on the fence regarding the Senate bill. Senators Lincoln (Arkansas) and Landrieu (Louisiana), the last two holdouts on bringing the bill to the Senate floor for debate, are covered by the campaign.
At the end of the day, the ads may need to be expanded to other states, so that a wider audience of people of color can be mobilized. Although they may not be able to influence the targeted Senators with potential votes, their potential campaign contributions flowing towards a more progressive challenger may be motivation enough. Either way, the time has come for us to act like our lives are on the line... Because in reality, they are.
###
Cliff Albright is a writer and political consultant. He has been a community activist for twenty years, focusing on race, politics and economic development, and he's hosted a radio talk show. Cliff has an MBA and a master’s degree in Africana Studies from Cornell. He has taught Black Studies at several colleges and universities, including currently at Georgia State University.