It's well documented that African Americans and other ethnic minorities have disproportionately higher rates of poor health, including infant mortality and most chronic conditions — heart disease, stroke, cancer, HIV/AIDS, asthma and diabetes, among others. Racial differences in health have persisted for so long that they're largely seen as a standard fact of life, even though, truth is, these differences are avoidable. So when President Barack Obama tasked Congress with sending a health care reform bill to his desk in 2009, the Congressional Black Caucus saw a huge opportunity.
"We'd already introduced a bill called the Health Equity and Accountability Act for the past several Congresses, so our work on this issue started long before the health care reform debate started," Virgin Islands Rep. Donna Christensen told The Root. In response to the president's charge, the CBC members promptly accelerated their efforts to tackle health disparities. They conferred with the National Medical Association and other black health groups, developed benchmarks that they wanted to see in the bill, formed a united front with other ethnic congressional caucuses and met on three occasions with President Obama.
Christensen, a physician and a chair of the CBC Health Braintrust, maintains that addressing race and ethnicity specifically in the legislation was critical because looking at differences in insurance coverage alone does not fully explain why blacks, on average, aren't as healthy as whites. Though pleased that the Affordable Care Act expands coverage through several means, including expanding Medicaid to include all people with incomes barely above the poverty level, she points out that health disparities persist regardless of insurance status. "Reports have shown that lack of insurance accounts for maybe 20 percent of what we see in health disparities," she says.
She also pushes back on the notion that health disparities are a matter not for government intervention but of individual behaviors — that if black folks would just eat less fatty foods and exercise more, then most of the problem would be solved.
"To some extent, of course it's about personal behavior, but a lot of it is environmental," she says, explaining that poverty and residential segregation are among the issue's biggest drivers. "People of color tend to live in neighborhoods where environmentally polluting industries are located. We have communities with no grocery stores and [an] excessive [number of] liquor stores, sometimes beyond what city statutes allow. All of these things contribute to the socioeconomic determinants of health."
Although the Affordable Care Act comprises many measures that originated with the CBC, such as diversifying the health care workforce and expanding community access to services, it ultimately falls short of changing socioeconomic drivers of health. Christensen is still proud that it includes most of what the CBC asked for — especially when, under the House Republican majority, those provisions are increasingly vulnerable.
What the Legislation Does …
Major aspects of the Affordable Care Act that CBC members fought to include are those that emphasize collecting health-disparities data and funding research. Federally supported programs, for example, are now required to collect demographic information. The legislation also elevates the National Center on Minority Health and Health Disparities to the more robustly funded level of an institute.
It may seem as if experts have been studying the numbers on and causes of health disparities for decades now, but the process has been inconsistent throughout the health care and public health systems. "If data is not uniformly collected, then we don't know where we are, and we can't monitor our progress," says Christensen.
The law also supports efforts to diversify the health workforce. African Americans are severely underrepresented, making up only 5.6 percent of all physicians. Research has shown that having providers from the same racial or ethnic background as patients in low-income communities tends to produce better health results (pdf). "There's an element of trust, and an understanding of where people are coming from, that produces better outcomes," says Christensen, citing the beneficial effects of knowing a community's language, cultural beliefs and traditions.
To attract more minority health care workers, the Affordable Care Act gives recruitment grants to historically black colleges and universities and other minority-serving institutions. It further extends funding for programs that help students attain degrees in science and technology at such institutions. The legislation also authorizes five years of support for schools, training programs and hospitals to develop and disseminate cultural-competency education training for all health care workers.
Finally, the Affordable Care Act expands geographic access to health care, since, even though poor communities have greater needs, they don't have enough medical professionals. The law provides additional funding for community health centers and the National Health Service Corps, under which the federal government offers loan-repayment and other incentives for providers who work in medically underserved areas.
… and What It Doesn't Do
While the health care reform law achieves a number of important steps to start eliminating racial difference in health quality, it also falls short, say policy experts. Brian Smedley, vice president for the Health Policy Institute at the Joint Center for Political and Economic Studies, underscores Christensen's argument that ZIP code determines a person's health more than genetic code. He argues that the law doesn't put enough resources behind community-based prevention to tackle the reasons that African Americans get so sick in the first place.
"Health care coverage and clinical prevention screenings are important, but they're not the root causes of health inequities. When you look across the gamut of diseases that people of color disproportionately suffer from, at their root are inequitable neighborhood conditions," Smedley told The Root, echoing the problems of abundant fast-food retailers, environmental injustice and a lack of access to outdoor recreational facilities in many low-income neighborhoods of color. He proposes that federal agencies, such as the Environmental Protection Agency and the Department of Housing and Urban Development, collaborate to make neighborhoods healthier.
Christensen concurs with this community-based strategy — in fact, it was one of the CBC's original recommendations. "We wanted to have 'health-empowerment zones' that would be designated because of their health disparities, and they would get help developing a plan with support from any federal agency, depending on their challenges," she says. "We did get something called Community Transformation Grants (pdf) for local organizations, which starts to get at that, but it's not fully what we wanted."
Protecting Health Care Gains
At the same time that advocates push for more to be done, House Republicans are vowing to use their majority to roll back the Affordable Care Act. On Tuesday, House Budget Committee Chairman Paul Ryan (R-Wis.) released a GOP budget (pdf) that repeals the Affordable Care Act, slashes $1 trillion from Medicare over the next 10 years and eliminates Medicaid, retooling it as a state-administered block grant. "This threatens everything we're trying to do," says Christensen. "I just don't understand it. This is not the kind of thing that you do if you care at all about the health of poor people."
Even though a repeal of the Affordable Care Act, which would require passage by the Senate and approval by the president, is unlikely, Christensen cautioned that legislative gains to narrow racial differences in health care are nonetheless vulnerable. "People just don't take health disparities seriously," she says, explaining that it wasn't until Democrats gained a majority in both houses of Congress in 2007 that the CBC's Health Equity and Accountability Act was even given a hearing. "When the Republicans are the majority, you cannot get support for these kinds of things."
In the meantime, the CBC is planning its defense strategy. The caucus will continue to push its own alternative budget, which provides full funding for the Affordable Care Act, and it has assembled a National Health Equity Commission to monitor the law's implementation. "The commission was founded specifically to protect the minority provisions and to ensure that they are implemented as robustly as possible," says Christensen. "So yes, we're prepared to push back."
Cynthia Gordy is the Washington reporter for The Root.