[House Hearing, 107 Congress] [From the U.S. Government Printing Office] RACIAL DISPARITIES IN HEALTH CARE: CONFRONTING UNEQUAL TREATMENT ======================================================================= HEARING before the SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY AND HUMAN RESOURCES of the COMMITTEE ON GOVERNMENT REFORM HOUSE OF REPRESENTATIVES ONE HUNDRED SEVENTH CONGRESS SECOND SESSION __________ MAY 21, 2002 __________ Serial No. 107-196 __________ Printed for the use of the Committee on Government Reform Available via the World Wide Web: http://www.gpo.gov/congress/house http://www.house.gov/reform ______ 86-436 U.S. GOVERNMENT PRINTING OFFICE WASHINGTON : 2003 ____________________________________________________________________________ For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpr.gov Phone: toll free (866) 512-1800; (202) 512�091800 Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001 COMMITTEE ON GOVERNMENT REFORM DAN BURTON, Indiana, Chairman BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California CONSTANCE A. MORELLA, Maryland TOM LANTOS, California CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York ILEANA ROS-LEHTINEN, Florida EDOLPHUS TOWNS, New York JOHN M. McHUGH, New York PAUL E. KANJORSKI, Pennsylvania STEPHEN HORN, California PATSY T. MINK, Hawaii JOHN L. MICA, Florida CAROLYN B. MALONEY, New York THOMAS M. DAVIS, Virginia ELEANOR HOLMES NORTON, Washington, MARK E. SOUDER, Indiana DC STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland BOB BARR, Georgia DENNIS J. KUCINICH, Ohio DAN MILLER, Florida ROD R. BLAGOJEVICH, Illinois DOUG OSE, California DANNY K. DAVIS, Illinois RON LEWIS, Kentucky JOHN F. TIERNEY, Massachusetts JO ANN DAVIS, Virginia JIM TURNER, Texas TODD RUSSELL PLATTS, Pennsylvania THOMAS H. ALLEN, Maine DAVE WELDON, Florida JANICE D. SCHAKOWSKY, Illinois CHRIS CANNON, Utah WM. LACY CLAY, Missouri ADAM H. PUTNAM, Florida DIANE E. WATSON, California C.L. ``BUTCH'' OTTER, Idaho STEPHEN F. LYNCH, Massachusetts EDWARD L. SCHROCK, Virginia ------ JOHN J. DUNCAN, Jr., Tennessee BERNARD SANDERS, Vermont JOHN SULLIVAN, Oklahoma (Independent) Kevin Binger, Staff Director Daniel R. Moll, Deputy Staff Director James C. Wilson, Chief Counsel Robert A. Briggs, Chief Clerk Phil Schiliro, Minority Staff Director Subcommittee on Criminal Justice, Drug Policy and Human Resources MARK E. SOUDER, Indiana, Chairman BENJAMIN A. GILMAN, New York ELIJAH E. CUMMINGS, Maryland ILEANA ROS-LEHTINEN, Florida ROD R. BLAGOJEVICH, Illinois JOHN L. MICA, Florida, BERNARD SANDERS, Vermont BOB BARR, Georgia DANNY K. DAVIS, Illinois DAN MILLER, Florida JIM TURNER, Texas DOUG OSE, California THOMAS H. ALLEN, Maine JO ANN DAVIS, Virginia JANICE D. SCHAKOWKY, Illinois DAVE WELDON, Florida Ex Officio DAN BURTON, Indiana HENRY A. WAXMAN, California Christopher Donesa, Staff Director Roland Foster, Professional Staff Member Conn Carroll, Clerk Julian A. Haywood, Minority Counsel C O N T E N T S ---------- Page Hearing held on May 21, 2002..................................... 1 Statement of: Christensen, Hon. Donna M., a Delegate in Congress from the territory of the Virgin Islands; Dr. Thomas LaVeist, associate professor, Johns Hopkins School of Public Health; Dr. Lisa Cooper, associate professor, Johns Hopkins University School of Medicine; and Dr. Elena Rios, president, National Hispanic Medical Association........... 112 Ruffin, John, Ph.D., Director, National Center on Minority Health Disparities, National Institutes of Health; Nathan Stinson, Jr., Ph,D., M.D., M.P.H., Deputy Assistant Secretary for Minority Health, Office of Public Health and Science; Ruben King-Shaw, Jr., Deputy Administrator and Chief Operating Officer, Centers for Medicare and Medicaid Services; Carolyn Clancy, M.D., Acting Director, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services......................................... 28 Letters, statements, etc., submitted for the record by: Christensen, Hon. Donna M., a Delegate in Congress from the territory of the Virgin Islands, prepared statement of..... 115 Clancy, Carolyn, M.D., Acting Director, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, prepared statement of............................ 95 Cooper, Dr. Lisa, associate professor, Johns Hopkins University School of Medicine, prepared statement of....... 126 Davis, Hon. Danny K., a Representative in Congress from the State of Illinois, prepared statement of................... 10 King-Shaw, Ruben, Jr., Deputy Administrator and Chief Operating Officer, Centers for Medicare and Medicaid Services, prepared statement of............................ 80 LaVeist, Dr. Thomas, associate professor, Johns Hopkins School of Public Health, prepared statement of............. 146 Rios, Dr. Elena, president, National Hispanic Medical Association, prepared statement of......................... 136 Ruffin, John, Ph.D., Director, National Center on Minority Health Disparities, National Institutes of Health, prepared statement of............................................... 32 Souder, Hon. Mark E., a Representative in Congress from the State of Indiana, prepared statement of.................... 3 Stinson, Nathan, Jr., Ph,D., M.D., M.P.H., Deputy Assistant Secretary for Minority Health, Office of Public Health and Science, prepared statement of............................. 55 Waxman, Hon. Henry A., a Representative in Congress from the State of California, prepared statement of................. 26 RACIAL DISPARITIES IN HEALTH CARE: CONFRONTING UNEQUAL TREATMENT ---------- TUESDAY, MAY 21, 2002 House of Representatives, Subcommittee on Criminal Justice, Drug Policy and Human Resources, Committee on Government Reform, Washington, DC. The subcommittee met, pursuant to notice, at 12:09 p.m., in room 2154, Rayburn House Office Building, Hon. Mark E. Souder (chairman of the subcommittee) presiding. Present: Representatives Souder, Cummings, and Davis of Illinois. Also present: Representative Waxman. Staff present: Christopher Donesa, staff director and chief counsel; Roland Foster, professional staff member; Conn Carroll, clerk; Julian A. Haywood, minority counsel; Karen Lightfoot, minority senior policy advisor; Josh Sharfstein, minority professional staff member; and Jean Gosa, minority assistant clerk. Mr. Souder. The subcommittee will now come to order. Good afternoon. I'd like to thank all of you for being here today. I want to start by recognizing and thanking Ranking Member Cummings for raising the issue of racial disparities in health care. We have scheduled today's hearing at his request. I would like to express my own serious concerns at the findings which we will be reviewing today. They ought to be of concern to all Americans because the Institute of Medicine has raised fundamental questions that could continue to weaken public perception of the health care system, threaten to perpetuate a health gap between minorities and nonminorities if not addressed, and further challenge already beleaguered health care providers. A comprehensive report by the Institute of Medicine released in March of this year found that minorities in America generally receive poorer health care than whites even when income, insurance and medical conditions are similar. The IOM found that this inequality has contributed to higher minority death rates from a host of chronic conditions. For example, relative to Caucasians, African Americans and Hispanics are less likely to receive appropriate cardiac medication or to undergo coronary artery bypass surgery even when factors such as insurance and income are taken into account. African Americans with end-stage renal disease are less likely to receive hemodialysis and kidney transplantation, and African American and Hispanic patients with bone fractures seen in hospital emergency departments are less likely than whites to receive pain medication. The report identified a number of causes for racial health disparities including language barriers, inadequate coverage, provider bias and lack of minority doctors. In addition to other recommendations for remedying these disparities which we will discuss more in depth, the IOM suggested that public awareness should be raised of this issue. We hope to further that goal today and discuss with representatives from the administration and other witnesses how best to close the gap. The IOM report is at least the fourth study released this year indicating racial disparities in the health care system. A January Centers for Disease Control and Prevention [CDC], report found that although the health gap between whites and minorities narrowed in the 1990's, substantial disparities remain. A Commonwealth Fund survey released earlier this month found that minorities do not fare as well as whites on almost every measure of health care quality. And a Harvard study released earlier this month found that African American patients enrolled in Medicare/Choice plans receive poorer quality of care than Caucasian patients across several measures. In November 2000, Congress passed the Minority Health and Health Disparities Research and Education Act of 2000, which is now Public Law 106-525, to confront many of the shortcomings noted in these reports. This law established the National Center on Minority Health and Health Disparities at the National Institutes of Health, provided increased fundings and incentives for minority health and health disparities research and new support for education for both health professionals and patients to increase positive health outcomes for minorities. It also provided funding for schools that are researching health disparities. While it is too soon to determine what effects this law has made, it is clear that more must be done to improve patient care for minorities. Particularly patients must have the ability to take control of their own health care decisionmaking. To do so will require improved patient education access to affordable care and more choice in making health care decisions. I look forward to today's testimony from the administration and health care leaders on how best to move toward meaningful progress, and I want to encourage the Department of Health and Human Services to move promptly toward tangible steps to help level the quality of care. Again, I thank Congressman Cummings for his leadership in bringing this important issue before us today, and I look forward to continuing to work in the subcommittee toward an equality of health care opportunities and care for all Americans. [The prepared statement of Hon. Mark E. Souder follows:] [GRAPHIC] [TIFF OMITTED] T6436.001 [GRAPHIC] [TIFF OMITTED] T6436.002 [GRAPHIC] [TIFF OMITTED] T6436.003 Mr. Souder. I'd now like to yield to Mr. Cummings for an opening statement. Mr. Cummings. Thank you, Mr. Chairman, and I thank you for agreeing to my request to holding this important hearing today. Today we will examine the progress that this Nation is making toward creating a health care system in which being a minority is not a mortality factor. As a Member of Congress and as an American of color, I deeply appreciate your willingness to examine the unequal treatment that minority Americans continue to receive within America's health care system, especially the compelling and disturbing evidence analyzed by a blue ribbon panel of scientists under the auspices of the Institute of Medicine. I join with you, Mr. Chairman, in welcoming all of our witnesses from the Department of Health and Human Services today, and particularly I want to thank Dr. Ruffin for being here under very difficult circumstances. Your presence here today speaks volumes about your commitment to fighting the persistent disparities we find in our Nation's health care system, and I thank you. And our second panel, we'll hear from our colleague Congressman Donna M. Christensen from the Virgin Islands, a physician who has a long-standing interest in issues surrounding minority health disparities; as well as Dr. Elena Rios, president of the National Hispanic Medical Association. Finally, let me also express a special welcome to the important witnesses who are joining us here today from Johns Hopkins University in Maryland's 7th Congressional District, which is, of course, the district I represent. Dr. Thomas LaVeist, the associate professor in the Bloomberg School of Public Health, and Dr. Lisa A. Cooper, who serves as associate professor on the faculties of both the Bloomberg School of Public Health and the School of Medicine. Mr. Chairman, in 1998, with strong encouragement from the Congressional Black Caucus, President Clinton committed this Nation to eliminating racially based health disparities in six specific areas by the year 2010. Those areas were infant mortality, cancer, cardiovascular diseases, diabetes, HIV infection, AIDS and immunizations. To their credit HHS Secretary Thompson and the Bush administration have reaffirmed this important national objective. Naturally, in order to cure and eliminate minority health disparities, we must first arrive at the understanding of their nature and causes. That is why I was proud to join with Congressman Bennie Thompson of Mississippi and other colleagues who care deeply about this issue in sponsoring legislation to create the National Center on Minority Health and Health Disparities at the National Institutes of Health. The Center's support for the IOM disparity studies was critical, and I want to recognize the efforts of my good friend and colleague Congressman Jesse Jackson, Jr., and the other Members of Congress who worked diligently to secure funding for the Center and for the study in the appropriations process. Today we will discuss the implications of that study entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The IOM's central conclusion is that Americans of color tend to receive lower quality health care even when the patient's income and insurance plans are the same, and that these disparities contribute to our higher death rates and poorer health outcomes from heart disease, cancer, diabetes, HIV/AIDS and other life-endangering conditions. This unfortunate indictment of our health care system by America's health care establishment is a monumental moral challenge to the policymakers of this great country. We have known for years that Americans of color die before our time from a wide range of illnesses, and that black mortality rates are higher than those of Caucasians. While lack of health care access has played an obvious role, the impact of racial biases and stereotypes on the quality of medical care received has been more difficult to assess. The IOM report demonstrates that these phenomena do exist, and we must now ensure that America's medical establishment comes to terms with the impact of race as an independent factor. When we know that the quality of care one receives in a doctor's office or in an emergency room may depend upon the color of one's skin, it is clear that we are dealing with a national civil rights issue of the highest order, and we must address it in those terms. Unless we dramatically expand the civil rights remedies available to people of color, the national 2010 initiative to eliminate racial and ethnic health disparities will simply fail. Title 6 enforcement is critical, and we must provide resources to the Office of Civil Rights so that it can aggressively enforce the civil rights laws and regulations that exist to protect Americans from discrimination in the health care system. Discriminatory effects of policies that limit minority access to medical care continue to be deadly, and without effective remedies, we will not see them go away. Our witnesses will address a range of other initiatives that must be undertaken if we were to achieve the administration's goal, the Nation's goal, of ending racial disparities in health care. As the IOM report tells us, education of both patients and providers improved data collection and monitoring, and increasing the proportion of minority health professionals are promiment among them. Mr. Chairman, I hope we can develop some consensus around implementing these initiatives so that the race will no longer be a predictor of negative health care outcomes, and I again thank you for holding this hearing. Thank you as well to all of our witnesses for being with us today. I look forward to hearing your testimony. Mr. Souder. Thank you. I now yield to Mr. Davis. Mr. Davis of Illinois. Thank you, Mr. Chairman, and let me first of all thank you for holding this hearing. I also want to commend the ranking member, Representative Cummings, for bringing this subject matter to this venue. I would like to ask for permission to submit my statement for the record, to revise and extend it, and also thank my young colleague who's graduating from medical school next month, Scott, for preparing it. And I look forward to attending his graduation, where I am scheduled to be the commencement speaker. I've been around this issue now for close to 40 years, and we've been talking about disparities. When it comes to minorities, there are disparities in everything that deal with quality of life in these United States of America. And I guess if there's anything that I've learned, one of the things that I've learned and discovered is that change is oftentimes a rather slow and subtle process. Matter of fact, people have been talking about problems of health care in a documented way in this country ever since the 1800's, when I guess one of the first real studies were put together in Massachusetts, something called the Shattuck report. And I find that the same problems that were being talked about then are being talked about now relative to what the issues are when it comes to health care. Obviously one of the real factors contributing to disparities facing African Americans and other minority groups is the disparity of income, is the issue of poverty, the issue of people being poor and not having resources. I always suggest that my mother died prematurely because she had to travel from the small town where she lived in Arkansas to the University Medical Center in Little Rock in order to get treatment for the dialysis problem, the kidney problems that she was having. I've known other individuals who could not get treatment because there was not the availability of resources where they were. And then, of course, you look in other places and there is an overabundance of resources. I represent a congressional district that has 23 hospitals in it, four medical schools, 25 community health centers, three or four large research institutes. And so the problem there is not necessarily the unavailability of care. But you can go 2 miles from the largest medical center complex in the country, which is in my congressional district, and find some of the most dire health needs and health statistics that exist. And so it seems to me that in many ways we have a certain amount of skill; we probably do some of the best medical education in the world. Something called the Flexner Report was put out, but--not only did it improve medical education, but it also put most of the black medical schools out of business, and they have not come back yet. I think it left only two, Howard and Meharry. So it seems to me that when we talk about disparities, we're really talking about how willing are we, as a Nation, to live up to the notion that we can move toward equal justice, equal opportunity. There is still a paucity of African Americans who are trained medical personnel. You look at the disparities in terms of the numbers of physicians and other professionals who are African Americans, and we still have the same problem. And so there needs to be a revamping, I think, of the system, more emphasis placed upon education, more emphasis placed upon life-style, more emphasis placed upon the desire and the need to be healthy. Of course, when it comes to racism and race orientation and all of those factors, we know that's not so much a factor of skill, but it's a factor of will. And so the struggle must continue. One of the things that Frederick Douglass taught that I try and subscribe to is that if there is no struggle, there is no progress. And so when you, Mr. Chairman, will hold a hearing on this subject in this committee, that is a part of the continuing and ongoing struggle. And you, Mr. Cummings, when you will raise the issue in this committee so that we can have the kind of discussion with the experts who have come to testify--and I want to thank all of them for coming and bringing their expertise. But what we really need to do is move toward a national health system, a national health plan, everybody in, nobody out, a system that takes the idea that health care is indeed a right and not a privilege. And a country with as much technology, with as much proficiency, as much resource and as much understanding as we have can, in fact, do that. So I thank you and look forward to the information that will be shared by our expert panelists. And I yield back the balance of my time. [The prepared statement of Hon. Danny K. Davis follows:] [GRAPHIC] [TIFF OMITTED] T6436.004 [GRAPHIC] [TIFF OMITTED] T6436.005 [GRAPHIC] [TIFF OMITTED] T6436.006 [GRAPHIC] [TIFF OMITTED] T6436.007 [GRAPHIC] [TIFF OMITTED] T6436.008 [GRAPHIC] [TIFF OMITTED] T6436.009 [GRAPHIC] [TIFF OMITTED] T6436.010 [GRAPHIC] [TIFF OMITTED] T6436.011 [GRAPHIC] [TIFF OMITTED] T6436.012 [GRAPHIC] [TIFF OMITTED] T6436.013 [GRAPHIC] [TIFF OMITTED] T6436.014 [GRAPHIC] [TIFF OMITTED] T6436.015 [GRAPHIC] [TIFF OMITTED] T6436.016 [GRAPHIC] [TIFF OMITTED] T6436.017 Mr. Souder. I'd like to yield to the distinguished gentleman from California, the ranking member of the full committee and member of the subcommittee, Mr. Waxman. Mr. Waxman. Thank you, Mr. Chairman. Democrat or Republican, conservative or liberal, I do not believe there is any Member of Congress who can ignore the findings of the March 2002 report from the Institute of Medicine called ``Unequal Treatment.'' This landmark report surveyed hundreds of scientific studies and found significant disparities in medical treatment and life-or-death outcomes by race and ethnicity. What the report found was tragic. Minorities are less likely to receive needed cardiac medication and cardiac surgery and are less likely to receive kidney dialysis or transplants. Minorities are also less likely to receive the most effective treatments for HIV. Minorities are also less likely to have their pain adequately treated. The list goes on and on. Here in Congress we are proud of our record of expanding NIH funding to develop new breakthrough treatments for diseases that cause immense human suffering, but these efforts are tarnished if we cannot make the treatments available. We have accomplished little if we permit the fruits of research to remain out of the reach of so many thousands of American citizens. It is a testament to the importance of this issue that the Subcommittee on Criminal Justice has called this hearing in bipartisan fashion, and I commend the Chair, Representative Souder, and the ranking member, Representative Cummings, for their leadership. Today, we will hear about the findings of the Institute of Medicine panel. We will also discuss solutions. It is not enough just to denounce health disparities. We must also take action to reduce them. The Institute of Medicine report includes a set of recommendations that I hope we will explore today. For example, one recommendation is that patients with public insurance receive the same managed care protections as those in private insurance. Because patients on Medicaid and other public insurance programs are disporportionately minorities, inadequate patient protections can increase health disparities. We need to ask whether the current administration is committed to following this recommendation. The Institute of Medicine panel also supports funding for innovative efforts to deliver medical care so that all patients, regardless of ethnicity or race, receive necessary treatments. We need to ask whether the current administration has supported full funding for such initiatives. The Agency for Healthcare Research and Quality has developed a program to accomplish some of these ideas. We need to ask whether the current administration is supporting full funding for these initiatives. The report calls for efforts to fight discrimination against racial and ethnic minorities in the health care system. We need to ask whether the current administration has backed away from a rule to prevent discrimination against Medicaid patients, many of whom are minorities. I am pleased that the administration has sent several witnesses from the Department of Health and Human Services here today. I am also pleased that several experts from medical professional associations and the Institute of Medicine have come for today's second panel. And I hope that today's hearing is not an end, but a beginning. By discussing the policies that are necessary to address health disparities, this hearing can be an important step toward a greater understanding of the commitment that Congress, as well as the medical profession, must make to provide equal treatment in the United States. Thank you very much, Mr. Chairman. Mr. Souder. Thank you. [The prepared statement of Hon. Henry A. Waxman follows:] [GRAPHIC] [TIFF OMITTED] T6436.018 [GRAPHIC] [TIFF OMITTED] T6436.019 Mr. Souder. Before proceeding, I'd like to take care of a couple of procedural matters. First, I ask unanimous consent that all Members have 5 legislative days to submit written statements and questions for the hearing record, that any answers to written questions provided by the witnesses also be included in the record. Without objection, it is so ordered. Second, I ask unanimous consent that all exhibits, documents and other materials referred to by Members and the witnesses may be included in the hearing record and that all Members be permitted to revise and extend their remarks. Without objection, it is so ordered. We begin with our panel of administration witnesses. We have excellent representation from the department today, for which I'd like to thank each of you and the department. As I'm sure most of you know, we also ask you to summarize your testimony in 5 minutes, and we will include your complete statement in the record. As an oversight committee, it's our standard practice to ask all of our witnesses to testify under oath, so if each of you could rise, I'll administer the oath. [Witnesses sworn.] Mr. Souder. Let the record show that each witness responded in the affirmative. As you have heard, Dr. John Ruffin, Director of the National Center on Minority Health and Health Disparities, has had some family matters that he has to attend to. And we want to express our sympathy to you and your family for your struggles. And because of that, we're going to have you give your testimony and then take some questions; and then you can be excused because we know you need to get on to that. But we thank you for taking the time to come to us today for this hearing. STATEMENTS OF JOHN RUFFIN, Ph.D., DIRECTOR, NATIONAL CENTER ON MINORITY HEALTH DISPARITIES, NATIONAL INSTITUTES OF HEALTH; NATHAN STINSON, JR., Ph,D., M.D., M.P.H., DEPUTY ASSISTANT SECRETARY FOR MINORITY HEALTH, OFFICE OF PUBLIC HEALTH AND SCIENCE; RUBEN KING-SHAW, JR., DEPUTY ADMINISTRATOR AND CHIEF OPERATING OFFICER, CENTERS FOR MEDICARE AND MEDICAID SERVICES; CAROLYN CLANCY, M.D., ACTING DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Mr. Ruffin. Thank you, Mr. Chairman. Good afternoon, Mr. Chairman and Mr. Cummings and other members of the subcommittee. I'm honored to join you today as the first Director of the National Center on Minority Health and Health Disparities for this special hearing on racial disparities in health. It is quite timely for me to update you on work of the new center to eliminate health disparities in light of the recent findings in the IOM report. To echo the words of the Deputy Secretary of Health and Human Services Claude Allen, these are issues that we in the Department have been confronting and working to resolve for many years. We are always alarmed, however, by the extent and impact of health disparities across our Nation. One of the great challenges we have faced over the past decade is the need to convince people that these problems are real and that they can be addressed through science. The IOM report helped greatly in this regard by serving to further document this crisis. As you know, the new center at the NIH was created by Public Law 106-525, the Minority Health and Health Disparities Research and Education Act of 2000. The timing could not have been better. The law has help us transition from the NIH Office of Research on Minority Health to a new center designated to address health disparity issues from a research perspective. The Center cannot do this alone, however. In fact, no single agency can do this alone. The health disparity crisis is multifaceted and will require a multidisciplinary approach from institutions across the country. Ours is an NIH-wide effort with the Center at the focal point. To reduce and eliminate health disparities, we will work with our other partners at NIH, but we will also work with other agencies and outside organizations and institutions involved in health disparities. We at the table this morning are networking among ourselves and with our constituencies. Only in this way will we be able to produce the results that will address the IOM recommendations. We have asked our stakeholders across the country what should we be doing that we're not doing. We have taken their advice and are now developing the NIH strategic plan and budget to reduce and, ultimately, eliminate health disparities. We also have three core programs provided in law that established our center. Our loan repayment program will give us an opportunity to produce a core of individuals who are culturally sensitive to health disparities. This type of program has worked well in other areas, such as HIV/AIDS. This work force--doctors, researchers, nurses, health care professionals--will sensitize even more individuals to the health disparities and help us combat the crisis. In fiscal year 2001, as a result of the creation of the Center and the creation of the loan repayment program, 8 months after the creation of the Center, 45 health professionals received loan repayment programs or loan repayment awards. We will set up a new round of competition for additional awards to be made this year. We must sensitize not only individuals, but also institutions to the health disparity crisis. Our endowment program, also provided by law, is available to section 736 institutions under the Public Service Act. This program will provide assistance for training and research and will bring more individuals into the health disparity research arena. Seven institutions were approved for awards in fiscal year 2001. Payments already have been made to five of these institutions, and payments are on the way for the other two institutions. We also are now accepting applications for the next round of competition and plan to make more awards this year. This is a collaborative effort between the National Institutes of Health and HRSA. The crown jewel of all of our efforts will be the creation of our Health Disparity Centers of Excellence around the country. We will establish these centers across the country to level the playing field supporting a wide array of institutions to engage in research, research training and health disparities. We have developed three mechanisms, Mr. Chairman, of support for this program in order to involve institutions at all levels of capability. We are currently accepting applications and plan to make awards this year. We also continue to buildupon our collaborative relationships with our HHS partners, many of whom are sitting at the table. Last year, we participated in 214 collaborative projects. This year we have received over 250 requests to cofund new initiatives from other NIH institutes and centers. This is a testament--it is an indication of the seriousness of the health disparity issues. While we would like to fund them all, there are congressional mandates within the new center that we're also committed to. However, we will maintain our obligation to several other NIH institutes and centers projects as well as our support to various OMH, AHRQ and CDC projects. With the Centers for Disease Control, we continue to support the Reach 2010 program of Racial and Ethnic Approaches to Community Health, which is entering its second phase. This program is a cornerstone initiative aimed at eliminating disparities in health status experienced by ethnic minority populations, and I'm sure those at CDC will talk more about their collaboration with the National Institutes of Health and our support for that program. The collaboration of the National Center on Minority Health and Health Disparities collaborated with the Office of Minority Health of the Department of Health and Human Services. It is broad-based, and it includes the goals of increasing research on minority health issues, collecting data, improving the data base, increasing the recruitment and retention of minority students in biomedical science and conducting community outreach and public education programs. There's a whole host of programs for which we collaborate with the Office of Minority Health with AHRQ. The Agency for Healthcare Research and Quality supports several programs aimed at understanding and eliminating health disparities that focus on community outreach, building research capacity and training. The Center provides funding for many of these projects, particularly the EXCEED program. It is our intent to continue to support these efforts and to continue to collaborate with our various partners. The Center continues to explore and develop future initiatives for research activities and programs aimed at reducing and eliminating health disparities. We will be meeting with our new advisory council in the coming weeks to discuss a number of new initiatives that we plan to launch. The Center is considering a cultural competency initiative which addresses the need for the development of cultural competency among health care providers and others who participate in health care processes. There is an urgent need, Mr. Chairman, for such individuals to have a firm grasp on how various belief systems, cultural bias, family structures, historical realities and a host of other culturally determined factors influence the way people experience illnesses and the way they respond to advice and treatment. We understand that such differences are real and translate into real differences in the outcome of care. We will explore with our advisory council the establishment of health disparity community centers that will conduct research, provide shared resources and provide the formal infrastructure to facilitate rapid advances in knowledge about communication among health disparity populations. These interdisciplinary efforts will result in new theories, methods and intervention that will contribute to addressing and ultimately eliminating disparities in health status. Finally, Mr. Chairman, the Center is grateful to the Congress, the administration, the NIH institutes and centers and to all of you for the overwhelming support that you have provided the Center in transitioning from the Office of Research on Minority Health to the National Center on Minority Health and Health Disparities. I'm proud of the progress that the Center has made over the past year in establishing its organizational structure and programs. We will continue to work with our many partners to explore new opportunities to reduce and eliminate health disparities. Through continued and increasing collaborative ventures, the Center will work diligently to define the health disparity issue for every American and garner support to ensure the health of all Americans. Health disparity is an issue that transcends minorities and other health disparity populations. Clearly, it is everybody's concern and it calls for shared responsibilities to effect permanent change. Each year we will be providing an annual report to the Congress on the result of our activities. We would be pleased, Mr. Chairman, to keep your subcommittee informed of our progress as well. Thank you for the opportunity to speak with you today. [The prepared statement of Mr. Ruffin follows:] [GRAPHIC] [TIFF OMITTED] T6436.020 [GRAPHIC] [TIFF OMITTED] T6436.021 [GRAPHIC] [TIFF OMITTED] T6436.022 [GRAPHIC] [TIFF OMITTED] T6436.023 [GRAPHIC] [TIFF OMITTED] T6436.024 [GRAPHIC] [TIFF OMITTED] T6436.025 [GRAPHIC] [TIFF OMITTED] T6436.026 [GRAPHIC] [TIFF OMITTED] T6436.027 [GRAPHIC] [TIFF OMITTED] T6436.028 [GRAPHIC] [TIFF OMITTED] T6436.029 [GRAPHIC] [TIFF OMITTED] T6436.030 [GRAPHIC] [TIFF OMITTED] T6436.031 [GRAPHIC] [TIFF OMITTED] T6436.032 [GRAPHIC] [TIFF OMITTED] T6436.033 [GRAPHIC] [TIFF OMITTED] T6436.034 Mr. Souder. Thank you for your testimony and congratulations on being the first Director. There will never be another first Director, so it has to be tremendously satisfying; and I appreciate your leadership. I have a specific question on HIV/AIDS. It is increasingly becoming more and more dominant in the African American and Hispanic communities. In fact, other groups have stabilized or dropped, but the number of black and Hispanic women becoming infected continues to increase each year. What efforts are you making to address this epidemic, and why do you feel that the current efforts are failing, because in this area it's actually increasing? Mr. Ruffin. Well, as you know, Mr. Chairman, there is an office at the National Institutes of Health which deals specifically--Congress has mandated an office that deals specifically with AIDS research at the National Institutes of Health. And that office collaborates with all of the other centers at the National Institutes of Health and also collaborates with the new center, that is the Center on Minority Health and Health Disparities. And also if it's--we have been able--there is a report, a new report, which I've just seen recently, that has come from that particular office that deals specifically with how they plan to address those specific issues. Clearly, they recognize that this has become of epidemic proportions within those communities that you just mentioned. And during a visit to-- their Web site, I noticed recently, clearly points out a number of initiatives that go to the core of your question. That particular office, as well as the NIH in general, is beginning to invest and expand funding in research infrastructure at minority institutions to increase capacity for support for HIV/AIDS research. We are also increasing a number of funded minority investigators, because we know that goes to the heart of it as well. We need to get more minority investigators trained in those fields. I think that the AIDS loan repayment program is a good way of doing that, because what we do by supporting those individuals is that we're saying to professionals around the country that if you go into AIDS research, what we will then do is that we will pay back those big loans that individuals have incurred in medical school, and other health professionals, to deal specifically with that whole issue. And I think as we begin more and more to train that cadre of researchers and get the word out, we will begin to address those issues, and in a major way. And there are a number of initiatives that are under way, and particularly in the Office of AIDS Research. Mr. Souder. So let me see if I understand: In your office, would the loan repayment program be under your office even--and one of the things your goal would be is to try to address the HIV/AIDS question in the minority communities? Mr. Ruffin. One of the things that happened at the NIH, and specifically with the creation of the new Center--the AIDS loan repayment program has been at the NIH for some time, but it was an intramural program. Individuals wishing to study and to come and do research on AIDS would have to come to the NIH and do that research in our intramural program. With the creation of the Center, we now have an extramural loan repayment program, which means that individuals, minorities as well as nonminorities, throughout the country who are doing research in these fields can do that research wherever they happen to be. Whether those individuals are in Wisconsin or anywhere, anywhere else in the country, they can now do research in those various areas. So now we have what is called an extramural loan repayment program that will help us to address those needs. The program sponsored by the Center also does something else, it's not just for MDs. It's for MDs, Ph.D.s, individuals in dentistry, osteopathic medicine. Because all of those health professional fields are going to play a role in our ability to eliminate health disparities. That's the new aspect that comes with the extramural loan repayment program that did not exist when we had the intramural, just the intramural loan repayment program at NIH. Mr. Souder. Is there a similar overlap in your outreach programs? Mr. Ruffin. Yes. Also I should add to that now--the loan repayment program is a program now that is extended in all of the institutes and centers at NIH. All of the institutes and centers can participate in the loan repayment program at NIH. This is the first year, of course, that we've been able to do that. Mr. Souder. Thank you. Mr. Cummings. Mr. Cummings. Thank you very much, Mr. Ruffin, for being with us. I want to go back to something that Congressman Davis talked about in his opening statement, when he was talking about the medical schools, African American, black medical schools. And it seems like this would be an ideal place, Howard and Meharry, to perhaps address these problems and at the same time do something for the students there, do something for the institutions. It's my understanding, for example, that the Howard School of Nursing has a program with Yale. Mr. Ruffin. Right. Mr. Cummings. Apparently, they send 4th year, I guess, students from Howard to Yale for a month, about a month, a little bit over a month; and they then get introduced to, I guess it is, high-level research. And it sounds like--when I heard you talking about research, I take it--I mean, is that the kind of thing that you're talking about also? I mean, these are nurses that would normally--in talking to the Dean at Howard, she tells me they would at the end of their 4 years just go on and begin to practice. But it opens up the door to research. Mr. Ruffin. Absolutely. By the way, the funding for that program comes out of the Center. So I'm pleased to take credit for that. Mr. Cummings. Wonderful. Mr. Ruffin. I must also say to you that partnering between minority and majority institutions is something that is highly encouraged. But I also mention in my testimony the creation of Centers of Excellence, Health Disparity Centers of Excellence. These centers would be distrubuted all over the country. You know, we have other kinds of disparities. As I listened to Congressman Davis talk about some of the situations in Arkansas, one of the other kinds of disparities that we have in our country is, ``geographical disparities as well.'' So getting these centers located to various places throughout the country, I think, is going to help. Many of the historically black colleges and universities will benefit from the creation of these centers because we have devised at NIH three different mechanisms to level the playing field. All of our programs are competitive programs, but institutions have to begin to compete on different levels. So we've created three different mechanisms for institutions to compete for these Centers of Excellence. One is what NIH calls an R-25 mechanism, which is simply a planning grant. Institutions which may not be ready for a center can compete for the planning grant, 3 years, up to $350,000 a year to plan for their centers. Other institutions, we have a mechanism which we call a P- 20; those are institutions--essentially an exploratory center. It's a corporate agreement. We hold hands with those particular centers to say, NIH is here. We're going to help you. We are going to be with you. We're going to walk until you are ready to go on your own. Those centers, individuals will compete on those. Then, of course, throughout the country we have institutions like Yale and others that we've invested in over the years that we want to also get involved in health disparity research. These are P-60's, and those institutions will be able to compete for health disparity grants as well. And so we are going to make those awards this September. We have had what we call technical assistance workshops all around the country over the last few months to tell people how to compete, before the fact to give them the information and to let them know what the expectations are. And I know from the interest that we're going to get a number of institutions around the country competing for these programs. Mr. Cummings. I know that you don't have a crystal ball, but you are in a position where at some point around 2010 somebody is going to--a whole lot of people are going to probably say, well, back then a few years ago a goal was set for us to address these disparities effectively by 2010, and I mean, what do you see happening? What do you--I mean, what obstacles are in your way from what you can see? And talk about money and talk about what we can do as the Congress to help you address these issues. I just--you know, I couldn't help but just listen, and listening to Congressman Davis, I have two relatives, a grandfather and a grandmother, who I know died prematurely; and I never even got to know them. And so, you know, we talk about quality of life, we also talk about the quality of life of having that grandparent there for that grandchild. Because, you know--and it just--I don't know if a lot of people realize how serious this problem is because, going back to my question, what do--where do you see us in 2010? Mr. Ruffin. Mr. Cummings, I'm encouraged; and one of the reasons I'm encouraged is for the very thing that's happening here today, that is, your ability and the ability of this subcommittee to listen to those of us who have been out in the communities and have listened to the individuals who are affected most. At the NIH and certainly with the creation of the new Center, we've tried to establish a new paradigm. And I think this new paradigm is going to lead to some results that perhaps we didn't get in the past and we will get by 2010. And that paradigm is this: What we're trying to do is to do what you're doing and that is to listen to the community. I mention in my statement that we go and we ask the community, what is it--and they're the ones after all who know best. We ask them, what is it that we should be doing that we're not doing. And when you give people a chance to talk, they generally tell you what it is that needs to be done. What we have to do as professionals is take the recommendations that they give to us, bring it back to an organization, an agency like the NIH, the premier biomedical research facility in the world, and try to take those recommendations and convert them to good science. And that's what we are trying to do. And think if we do that, I think the result this time around is going to be different. And so my perspective, looking through my crystal ball, is very favorable about what's going to happen as it relates to health disparities. Mr. Cummings. Just one last question. What's the relationship between NIH training programs that you were describing and those who--HRSA's Bureau of Health Professionals that aim to train minority clinicians; and is it a complementary relationship? Mr. Ruffin. HRSA has for some years, as you know, had the Centers of Excellence program. These are 736 institutions that were established in public law. They're not all minority institutions, some of them are research-intensive institutions, but a great deal of them are minority institutions. The law that established the center has allowed us the ability to make loans--I'm sorry, endowments to many of those institutions; and funds from those endowments can be used for a multiplicity of purposes. Not all of those 736 institutions would qualify. It is the institutions among the HRSA Centers of Excellence that are doing good science, but that have small endowments. And we're concentrating on those institutions to give them the necessary resources to build a strong biomedical emphasis. Mr. Cummings. Again, we thank you for--under the circumstances, for being with us. And you know our spirit and our hearts are with you. And our prayers. Mr. Ruffin. Thank you. Mr. Souder. Mr. Davis. Mr. Davis of Illinois. Thank you very much, Mr. Chairman. Dr. Ruffin, let me first of all congratulate you on your appointment, and I also would commend the appointing officer for making what I would think was a very wise selection. Mr. Ruffin. Thank you, sir. Mr. Davis of Illinois. Your testimony actually is some of the most stimulating that I've heard in a long time in terms of possibilities for serious movement. I also want to commend you on the program activity that has already been generated, especially the loan repayment which deals with a real issue and a real problem that people have. And then the whole business of trying to train more minority researchers. I can tell you, I've participated in so many research projects where we first had to train the principal investigators until I just got tired of it; you know, I'm saying this is ridiculous that these are the people who are in charge, and we've got to train them. And so I'm so pleased to see that. And also I'm pleased to see that there would be some focus on trying to engage the historically black colleges and universities more into the activity. I think that we've made a tremendous amount of progress. When we had the old health rights programs when we really saw health in a big way in communities, still many of the people that we're talking about are poor. I mean, many of the people with the greatest amounts of disparity, notwithstanding the fact that there are some other people that have some too, but poor people. And it seems to me that poor people require certain kinds of help and process; and you mentioned outreach, and that's my question. When there was a great deal of outreach, I thought we were making serious progress. But then we killed off that activity prematurely, again, I think when we killed off the old OEO program and activities. And how prominent do you see outreach becoming as a part of the focus of the Center as we deal with the disparity question? Mr. Ruffin. It's a major part. And not only that, but I mentioned to you that we ask people constantly, what is it that we ought to be doing that we're not doing. And this is one of the issues that come up often. And there are several ways that we're going to try and do these kinds of things over time. One, of course, is, as I said, trying to develop the centers in strategic places around the country. But in addition to that, one of the other issues that has been raised prominently is the role of community and community-based organizations, all in all, of what we do. I have to say that at NIH is one of those; that's one of those areas where there is a gap, and that is the participation of community-based organizations. We've had some activities where community-based organizations have participated with academic institutions in various partnerships. But there, terms of developing a role, a very significant role, for community- based organizations, I think that would enhance to a great extent our ability to do effective outreach. And we're going to continue to develop some programs in that area as well. The community is demanding that we develop some programs in that area. So we have an office in the new Center that is devoted exclusively to outreach and a relationship with community-based organizations and trying to address that very issue that you're mentioning. Mr. Davis of Illinois. Let me just thank you very much. Your words to my ears are like manna from heaven, because I don't believe that you could do a lot of things for people, that you have to do things with people. And if you get people engaged and involved and have you them moving in concert, then I think you can see some progress. And so, you give me a great deal of hope. And I certainly look forward to working with you and hope that we can move this process along. And I thank you very much, Mr. Chairman, and yield back. Mr. Ruffin. Thank you, sir, and thank you for allowing me to testify today. Mr. Souder. Thank you, Dr. Ruffin. You're free to leave. We appreciate once again that you stayed today. Mr. Souder. Next, we move to the testimony from Dr. Stinson. Dr. Stinson. Good afternoon. I am Nathan Stinson, the Deputy Assistant Secretary for Minority Health and the Director of the Office of Minority Health in the Department of Health and Human Services. I thank you for the opportunity to testify before the subcommittee today. As has been previously stated, it is very clear that health disparities are not a new occurrence. In fact, the 1983 issue of Health, United States, which is the annual report card on the health status of the American people, documented that, although significant progress had been made in the overall health picture, there still were persistent and chronic disparities experienced by racial and ethnic minority populations versus the United States as a whole. During the final evaluation of Healthy People 2000, where the experts in the different health fields testified about the progress made over the past decade, almost without exception they talked about how the health in general had improved but how disparities among racial and ethnic minorities had either persisted or in many cases had gotten worse over the past decade. This hearing, as Dr. Ruffin said, could not be more timely. There are many efforts that are occurring not only within the Department of Health and Human Services but also in State and local communities to address a problem that we know will not go away unless we give it direct and focused attention. The Department of Health and Human Services is currently involved in a process of developing a comprehensive overall plan to address and to marshal the assets that it has in all of the different agencies to address the disproportionate burden of illness on racial and ethnic minority populations. The Office of Minority Health, because of its role as the adviser to the Assistant Secretary of Health and the Secretary in health-related matters as they affect racial and ethnic minority populations, has the opportunity to play a very key role in shaping not only the policy aspects on how to address these problems but also the implementation of any of the particular programmatic activities within the Department. I am going to talk very, very quickly about five specific areas as ways that the Office of Minority Health implements its programs or influences the Department in its programmatic development and implementation. The five areas are not in any particular order of priority, but I want to start out by talking about strategic communication and information dissemination. It is very, very clear that it is important to develop the appropriate health messages, to deliver those messages in a way that individuals are receptive to and, as importantly, to gauge how effective we have been in producing an enhanced knowledge base and sometimes a change in any particular behavior. The Office of Minority Health has periodic communications that it makes available to over 10,000 organizations and individuals. We have a Web site that is available for organizations and the public at large, and we have also tried to enhance the capacity of the resource center from a science and research capability to try to provide the opportunity to create a one-stop shopping place for organizations and for individuals who have any interest in the areas of minority health. One of the specific and new activities is a partnership that we have at ABC Radio with their urban network radio stations around the country where the Department of Health and Human Services is providing ABC Radio with the medical content and the messages that they then play on their affiliates around the country at no cost to the Department, but it is a very important way to reach the population at large. Clearly, the Department cannot do this by themselves. Partnerships are crucial to addressing the problems of health disparities around this Nation. We work closely with State departments of health. Many of them have offices of minority health and have formed a minority health network where we work very closely with the efforts that are occurring within individual States and minority communities. It is very, very important, as Dr. Ruffin said, that the recommendations, the program development, the implementation are really based on good science. So the Office of Minority Health, because it has a direct appropriations, is also able to fund some demonstration programs to test some innovative ideas and test out some different opportunities, outreach to minority communities and then try to help translate some of the lessons learned and some of the models that work into the broader categorical programs within the Department. One of the last two areas I want to talk about is policy development. Clearly, it is very crucial, as we look at how effective our programs are in attaining the outcome we are interested in, is that we make sure that any type of particular policies that we have do not create any barriers to what happens at the State and local level, but, more importantly, that we actually have a systematic way of policy development and implementation that actually enables the actions that are necessary to address health disparities to occur and, therefore, are very proactive in overcoming any perceived barriers that are there. Last is the collection of racial and ethnic data. This area is extremely important. It is important that we understand where the potential problems are, but it is also important in that we have complete and comprehensive information so that we know whether or not we are actually producing the outcome we want, we know whether or not it is time to change what we are doing because the application of those resources are not going to likely deliver the output that we are interested in, and that we also know what other areas of disparities are starting to develop in any other particular group or any other particular condition. As Dr. Ruffin said, quite directly and very completely, this is a very unique time that we have to step back and really look at what is it that we need to do to keep this Nation healthy and strong, what do we need to do now as we look at the objectives and goals that we have for Healthy People 2010, what do we need to do now to assure that the investments that we make as a Nation are going to give us and allow us to reach that ultimate outcome at the end, which is a healthier Nation. Thank you again for the opportunity to testify before the subcommittee. Mr. Souder. Thank you. [The prepared statement of Dr. Stinson follows:] [GRAPHIC] [TIFF OMITTED] T6436.035 [GRAPHIC] [TIFF OMITTED] T6436.036 [GRAPHIC] [TIFF OMITTED] T6436.037 [GRAPHIC] [TIFF OMITTED] T6436.038 [GRAPHIC] [TIFF OMITTED] T6436.039 [GRAPHIC] [TIFF OMITTED] T6436.040 [GRAPHIC] [TIFF OMITTED] T6436.041 [GRAPHIC] [TIFF OMITTED] T6436.042 [GRAPHIC] [TIFF OMITTED] T6436.043 [GRAPHIC] [TIFF OMITTED] T6436.044 [GRAPHIC] [TIFF OMITTED] T6436.045 [GRAPHIC] [TIFF OMITTED] T6436.046 [GRAPHIC] [TIFF OMITTED] T6436.047 [GRAPHIC] [TIFF OMITTED] T6436.048 [GRAPHIC] [TIFF OMITTED] T6436.049 [GRAPHIC] [TIFF OMITTED] T6436.050 [GRAPHIC] [TIFF OMITTED] T6436.051 [GRAPHIC] [TIFF OMITTED] T6436.052 [GRAPHIC] [TIFF OMITTED] T6436.053 [GRAPHIC] [TIFF OMITTED] T6436.054 [GRAPHIC] [TIFF OMITTED] T6436.055 [GRAPHIC] [TIFF OMITTED] T6436.056 [GRAPHIC] [TIFF OMITTED] T6436.057 Mr. Souder. Next we will move to Dr. Ruben King-Shaw, Deputy Administrator for the Center for Medicare and Medicaid Services. Mr. King-Shaw. Mr. Chairman, I thank you for the opportunity to talk about something for which I have such a long-standing compassion. Such a commitment, as expressed by the secretary and the President, is quite telling at this important time in health care policy. Let me first say, for CMS, this is a central issue to who we are and what we do, as truly the largest health insurance company in the United States, if not the world. When we embrace the concepts of eradicating disparities, it has real meaning. We spend $1 out of every $3 in the health care system nationally, and in many markets we spend 50 percent or more. So our activity in this area has an implication far beyond the 70 million beneficiaries that we serve directly through Medicare, Medicaid and SCHIP, but because of some other things that we do, such as survey and certification and the market force for provider reimbursement and other types of standards of care and quality, I would suggest that we have an impact across the entire health care finance and delivery system. So we approach these issues of health disparity with a heartfelt understanding that these issues are not minor, these people are not minor, and our efforts must not be minor. So we do not conceive of this as a minority health initiative per se. We perceive of this as efforts to eliminate disparities among ethnic communities. There are issues of fairness and integrity and equality and I would submit part of the American promise that we make to all Americans and those that come to this country. So the strategies that we have pursued at CMS tend to fall into a few areas that are logical and natural. First, we have embraced evidence-based medicine and encourage it in every way. Using clinical practice guidelines and standing orders and performance-based measures is one of the ways we continue to move forward on these important issues. We also focus our efforts on access and delivery. We do have a very ambitious research agenda. It is highlighted in the testimony. We can talk about what those initiatives are, but to a very real extent the difference we make is in adjusting the delivery system itself to be more appropriate in delivering health care to people of ethnic populations who are underserved in the medical community or suffering from adverse outcomes or by redirecting our resources to improve access to the existing programs in ways that are successful. We also are committed to endemic organizational change at CMS, so we have a program executive who is full-time dedicated to these efforts, Kevin Nash, who is with me here today. We have open-door policy forums that allow people from across the country who care about the issues of diversity and disparity to be part of our discussion, priority setting and decisionmaking. We have an Equality Council which sees the addressing of these disparities as part of its core function. It is a quality issue as well. Daily decisionmaking must reflect these priorities as we do our job in all of the ways in which we do it. There are several actions that I can highlight. In the interest of time, I will refer to the testimony. There are some things which I think are important to note. We do have strong existing partnerships with members of the communities we serve that can enhance our ability through research and delivery and other initiatives to make a difference. These include the four historically black colleges of medicine: Howard, Meharry, Morehouse and Drew. We also include in our efforts ways to have stronger relationships with colleges of pharmacy, such as Bayamon, Xavier, Hampton and also Southern. We also do a number of things called the Hispanic Agenda for Action where we partner with leading Hispanic organizations, both clinical and communities, as we do with Asian American, Pacific Islanders and American Indian populations. But among the most successful initiatives we have established has been the notion of embracing demonstration projects to truly improve the outcome of care for the people we serve. These have included cancer prevention and treatment demonstrations as authorized by BIPA, a number of clinically and linguistically appropriate initiatives, as well as disease management and case management initiatives that are specifically designed to improve outcomes in ethnic populations such as HIV, cancer and end stage renal analysis. In summary, CMS will continue to do its best efforts in this area, whether we are talking about demonstration, research, intervention strategies, quality improvement organizations who are dedicated in developing best practices to improve the health outcomes of all the people we serve, including ethnic populations and racial groups, that we will continue to do this as a part of our mandate and our mission for the centers of Medicaid and Medicare services. I look forward to having more discussion in the question and answer session on this topic. [The prepared statement of Mr. King-Shaw follows:] [GRAPHIC] [TIFF OMITTED] T6436.058 [GRAPHIC] [TIFF OMITTED] T6436.059 [GRAPHIC] [TIFF OMITTED] T6436.060 [GRAPHIC] [TIFF OMITTED] T6436.061 [GRAPHIC] [TIFF OMITTED] T6436.062 [GRAPHIC] [TIFF OMITTED] T6436.063 [GRAPHIC] [TIFF OMITTED] T6436.064 [GRAPHIC] [TIFF OMITTED] T6436.065 [GRAPHIC] [TIFF OMITTED] T6436.066 [GRAPHIC] [TIFF OMITTED] T6436.067 [GRAPHIC] [TIFF OMITTED] T6436.068 [GRAPHIC] [TIFF OMITTED] T6436.069 Mr. Souder. Last we will hear from Dr. Karen Clancy, Associate Director, Agency for Healthcare Research and Quality. Dr. Clancy. Good afternoon. I am Carolyn Clancy, the Acting Director of the Agency for Healthcare Research and Quality, or AHRQ. I am very happy to be here today to discuss the relationship of the research we support to the issues raised by the Institute of Medicine report on unequal treatment. Our research provided an important underpinning for the report and AHRQ is beginning to respond to the issues raised by that report. I would like to leave you with a sense of that. I would like to make two observations. First, to make clear that we are a research agency but the work that we sponsor actually complements the work supported by NIH. Where NIH's biomedical agenda focuses on what science is needed to address pure prevention and treatment of disease, what treatments can work, our research focuses on effectiveness or what does work for individual patients in typical or real-world practice settings. In addition, our research, besides focusing on the content of clinical care and the persons with those illnesses--because, after all, many persons come with two or three different diagnoses--we focus on how that care is organized, the impact of health insurance, what sorts of settings people get their care in, and so forth. The second observation is the issue of poor quality care is most marked and severe for members of racial and ethnic minority populations, but it is also a problem for all of us. We sponsored a study that was cited in the report and was published 2 years ago in the New England Journal of Medicine which asked: What proportion of Medicare beneficiaries who have had a heart attack are receiving an evidence-based, life-saving treatment, also known as clot busters, or thrombolysis? What the study found was that 59 percent of white men, 56 percent of white women, 50 percent of black men and 44 percent of black women who met the criteria for these drugs were receiving them. So it seems to us that there are two important messages. First and foremost, this study confirms the results of far too many studies showing that African Americans are significantly less likely to receive evidence-based lifesaving treatments, and it underscores Dr. King-Shaw's points about the importance of evidence-based medicine. But the second take-home message is that 59 percent of eligible patients, which is the best that we did, is not so great and that there is room for quality improvement for all of us. We therefore believe and it is a point which has been made by Dr. Blend and others, that reducing and eliminating disparities in health care is a very critical part of overall strategies to improve quality. As I noted, many of our studies contributed to the IOM report Unequal Treatment. One in particular created a lot of attention and as a practicing physician makes me embarrassed to tell you about. This was a study that showed that physicians are part of the problem, not part of the solution. Well-trained actors were trained to portray patients with chest pain. They used literally the same wording and language, all of the information provided to the doctors and interacted with the videotapes of the actors, told them they had the same income, occupation, and so forth. What the study found was that the physicians were significantly less likely to recommend evidence-based treatment for older African American women, and this study prompted a great deal of discussion and concern. I would like to tell you a little bit about our efforts to reduce and eliminate disparities. We have pretty much informed our researchers that we have heard enough descriptive information and, as IOM study demonstrates, the time to simply describe the problem any more fully has probably passed. Now we need to focus on understanding why these disparities in health care occur and what strategies can be used to reduce and eliminate them. The centerpiece of our research program is called EXCEED, Excellence Centers to Eliminate Ethnic and Racial Disparities in Health Care. This is a 5-year grant that began in 2000, and it is a collaborative effort with NIH, specifically Dr. Ruffin, and HRSA, as well as some other local foundations. Each of these focuses on four to seven studies organized around a particular problem and organized around the six priority areas of reducing racial and ethnic disparities in health initiative. In addition, we have supported nearly 200 grants and contracts just since 1999 alone. In response to the Minority Health and Health Disparity Act of 2000, we have also begun this past year to develop a very specific focus on community-based participatory research. Too often, as many know, minority communities and other communities believe that research is something that is done ``to us.'' The purpose of this focus on participatory research is to shift that framework so, from the community's perspective the understanding is that there will be nothing ``about us without us.'' We look forward to reporting on our future plans to you soon. We are also supporting some very important training initiatives to make sure the perspectives of the research community accurately reflect the diversity of the current population. Importantly, a unique function of AHRQ is to develop the tools to measure and monitor our progress, to help us make sure that Mr. Cummings' crystal ball is as clear as possible. We support the development of quality measurement tools. In fact, the Minority Health and Health Disparity Act has asked us to report to Congress on the state of the science for quality measurement for disparity populations; and we will be submitting that to Congress this year. Very importantly, our reauthorization in 1999 directs the agency to produce two annual unprecedented reports starting in fiscal year 2003. One will report on the overall state of the quality of health care and the other is called the National Health Care Disparities Report. This will detail prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in minority populations. The two reports are closely linked. The disparities report will report on quality measures presented by race, ethnicity and socioeconomic status. It will also report on consumer and patient assessments of health care quality and quality measures for priority areas. Mr. Chairman, we are very proud of our tradition of supporting research to identify and address racial and ethnic inequities and the outcomes of health care services in this Nation. The findings of the IOM report are very sobering, but we believe there is a very important opportunity to establish elimination of disparities as a priority. Health care is a core component of efforts to improve quality of care for everyone, and our current initiatives are designed to reinforce and strengthen that opportunity. Thank you. Mr. Souder. Thank you. [The prepared statement of Dr. Clancy follows:] [GRAPHIC] [TIFF OMITTED] T6436.070 [GRAPHIC] [TIFF OMITTED] T6436.071 [GRAPHIC] [TIFF OMITTED] T6436.072 [GRAPHIC] [TIFF OMITTED] T6436.073 [GRAPHIC] [TIFF OMITTED] T6436.074 [GRAPHIC] [TIFF OMITTED] T6436.075 [GRAPHIC] [TIFF OMITTED] T6436.076 [GRAPHIC] [TIFF OMITTED] T6436.077 [GRAPHIC] [TIFF OMITTED] T6436.078 [GRAPHIC] [TIFF OMITTED] T6436.079 [GRAPHIC] [TIFF OMITTED] T6436.080 [GRAPHIC] [TIFF OMITTED] T6436.081 [GRAPHIC] [TIFF OMITTED] T6436.082 Mr. Souder. I would first like to start with a question for Dr. Stinson. First, let me double-check, do you agree that married households generally fare better than nonmarried households in health care? Dr. Stinson. Let me answer it this way. There has certainly been some studies that have speculated that married households fare better than unmarried households. Most of the research has surrounded the health outcomes for individuals which are one parent or unmarried households; and they clearly have shown, in those types of settings, there may be increased behavioral, mental health problems and higher incidence of substance abuse. Also, unmarried women at any age have a risk of having a child of low birth weight, which has a whole list of potential health complications. Much of the research has been done looking at one parent or unmarried households and have looked at a lot of outcomes which have been troubling. There certainly has been an inference that in two parent or married households there are some protective natures, because it may indeed create a different type of environment with certain stabilization around supervision, nurturing, et cetera, that may have some beneficial effects on health. Mr. Souder. I really appreciate your carefulness in distinctions. That is my familiarity, is that it is predominantly related to children and studies related to child- bearing mothers. Do you know if you are just single, no children? Part of the assumption is, if there are two people there, there is a certain amount of commitment and responsibility and prodding each other, as my wife particularly prods me to get things checked out. Do you know much about that? Dr. Stinson. I am clearly not an expert on those studies. I don't know the answer to your question. Mr. Souder. Let me ask, because there actually has been an increase in the percent of marriage and minority individuals. The bottom line is that we know, freezing insurance and freezing income, there are still disparities. Part of the question is, in freezing this variable, what would happen? If in fact some of the improvement in relative disparities--is that improvement partly related to the marriage variable as well? Does anybody have any idea regarding that data? Dr. Clancy. Our studies have not specifically looked at this with regard to race and ethnicity, but there are many studies in the literature which support the contention that being unmarried is not associated with good health in men in particular. Every time it comes up at a meeting and someone asks why is that, usually the researcher steps back and says, ``I am not sure I want to speculate on why that is.'' It clearly is a very important factor for men's health. Mr. Souder. I was a staffer for Senator Coates for 10 years before I became a Congressman, and I worked with Senator Coates to try to encourage HHS to have this data in it. It is not clear how much we can actually affect that behavior pattern or what role it is of government to affect that behavior pattern, but we ought to know from a scientific standpoint whether or not marriage is one of the variables. Let me ask another controversial question, and that is in relations to Hispanics, and this would be very difficult to find, but is part of the disparity the illegal immigrant question and even an unwillingness to respond because of fear of the researcher? How much of the disparity is in that subgroup? Mr. King-Shaw. Mr. Chairman, in southern Florida, clearly when you have a population that arrives in this country that is formally disconnected from the health care system in any way except the emergency room, then you have all of the problems that are generated by not having a continuous relationship with the health care system. Primary care, diagnostic treatment, education, case management, all those things that would normally be a part of a connected person to health care would not be in an immigrant population or a migrant population. They tended to have much of the same characteristics. There is also the issue that people can arrive in this country not having achieved strong health status before they arrived. So there is no connection with the health care system going forward to keep them healthy, but it can be very difficult to become healthy when you arrive with a situation which has already put you behind the eight ball, so to speak. That is anecdotal. Most people would agree if you are from areas that are high in the population of immigrant individuals, I am sure there is some quantifiable data that could bear that out. I just can't cite any at this particular time. Dr. Stinson. Mr. Chairman, your question points out how difficult it is in trying to parse out all of the different factors that play a role in health disparities. Some of the literature shows in some of the newly arrived immigrants, some of the individuals from Asia, some of them actually have better rates in some of the diseases, especially in that population in cancer, than the individuals who stay here and become U.S. citizens. Over the years, that cohort ends up developing some of the disparities that we have seen, even though, when they first arrived, they did not exhibit any differences in the population in general. It makes it difficult to generalize or to assume that in every situation, every group, that disparity existed prior to immigration to this Nation. Mr. Souder. I appreciate that. Often, we do not understand the complexity of it, and the research needs to make sure that we have all of the variabilities. We all know if you do not have access to a provider you are certainly going to be less healthy, or if you do not have knowledge of what is available you are going to be less healthy. But we are not doing that great with any part of the population, as has been pointed out, and so some are internal variables. I yield to Mr. Cummings, and hopefully we can finish this panel before we leave to vote. Mr. Cummings. Dr. Clancy, I am concerned about the funding for the EXCEED program and other initiatives with regard to health disparities. Correct me if I'm wrong, it is my understanding that the President has asked that your agency budget fall from $300 million to $251 million next year? Dr. Clancy. That's correct. Mr. Cummings. And I also understand that $192 million of the $251 million is protected for specific projects; is that correct? Dr. Clancy. That's correct. Mr. Cummings. That means that $49 million must be cut from the remaining $108 million. Does EXCEED fall into the group of programs that collectively face that 46 percent cut? Dr. Clancy. Yes, it does. Mr. Cummings. How do you see that affecting EXCEED? It seems like it is getting ready to be--it apparently is going to be cut substantially? Dr. Clancy. The impact on the Centers for Excellence will be less than 46 percent because the core funding for some of them comes from the National Center for Minority Health and Health Disparities and a little bit from some other foundations. So the net impact overall across the nine centers I would guess would be somewhere between 25 and 30 percent cut in the outyears. The majority of funding does come from AHRQ, though. Mr. Cummings. I know you have to support the President's budget, but when you consider the fact that literally as we sit here--and I heard your testimony about how this is a problem that does affect a lot of people--but as we sit here, people are dying needlessly. One of the things that was so painful for me to read this, because I had a relative who had an amputation, part of the report talks about if you are African American, you have a 3.6 percentage point times chance of having a lower limb amputated if you have diabetes, same stage. For the life of me, there is something wrong with this picture. And cutting the EXCEED program--and 25 percent is a substantial cut in anybody's estimation--I was just wondering how do you feel about that? People are literally dying, that is the other piece. People are dying, and they are dying early. I was just curious. Dr. Clancy. All of the research efforts that you have heard about from Dr. Ruffin and from myself, and the others on the panel, it is discouraging that it takes time to buildup a critical mass of researchers to actually establish relationships with communities and local change agents, who can take the findings from the work and actually ensure that they are translated into practice and institutionalized. The timing for the cuts for these centers will be very difficult because they will be at a point where they are beginning to test and evaluate some potential strategies for reducing or eliminating disparities. Mr. Cummings. Dr. Stinson, you were talking about the various programs that you all have to inform people and what have you. If you read the report, it seems like you can get the information to the people, but then when they get in the doctor's office--and a lot is just getting them to the doctor's office. At the doctor's office, they face another hurdle. I was just wondering, how do you get to that? Are you following me? Dr. Stinson. Yes. It is crucial that we do not blame the individual, put all of the burden on the person in that it clearly is important for all of us to understand what we need to do as far as eating right and exercising, all those things that can help us remain healthy. But, as importantly, we have to really engage the health professionals in a different way, in a more direct way, in a way that they understand that the foundation of delivering health care that is of the highest quality is that they have to communicate effectively with whoever comes through their door. That means they have to understand that, just like anybody else, we have to be very objective, be very deliberate and very focused on how do we address the problems of the patients that come through the door. The pledge that all health professionals make in delivering the best quality of care just does not happen naturally. You have to think about your practice, you have to think about how you can provide the best care to every patient that comes through your door. Mr. Cummings. I agree with that. We have to go to a vote, so I have to cut you off. I am just saying this as a general statement, not directed to any particular person. I wish people in government would look at these problems with the urgency they would look at them if it was their relative, their wife or child, that was involved. Then I think people would literally go crazy trying to solve these problems. Every human being has value, and I just think that it gets so frustrating. When I read that report, I felt like vomiting. It was so alarming to think that so many people are dying. A cut here, a cut there, it is just a few people. They are going to die, suffer, so what? Then when I think about the things that we concern ourselves with, it just seems--the unfairness continues. I thank you all for being here. Mr. Souder. I thank you as well and certainly encourage the outreach efforts. I have participated in two minority health fairs in Fort Wayne, Indiana, where they give free blood pressure and other screenings. They do them at community-based organizations or a mall where the people actually go, which is one of the really important things in the outreach. I think if we continue to all be aware of these health disparities and work at it, we can all make progress. Mr. Waxman also had some questions for this panel, which will be submitted for the record. We will temporarily recess, and we have a number of votes, so we will be a little while. The hearing stands in recess. [Recess.] Mr. Souder. Call the subcommittee back to order. And as you've heard our procedure, we need to swear our witnesses in. Congresswoman Christensen does not have to be sworn in. It's a long-standing protocol but I understand it's because when we take our oath of office we already take this oath. So if Dr. Rios and Dr. Cooper could stand. [Witnesses sworn.] Mr. Souder. Let the record show that both witnesses responded in the affirmative. Now, if you can summarize your testimony and we'll submit your whole statement in the record, and I'll be a little liberal with that. I appreciate how long you had to wait and I appreciate your willingness to stay for this panel and put up with our voting patterns in the House. With that, Congresswoman Christensen, we'll let you begin. STATEMENTS OF HON. DONNA M. CHRISTENSEN, A DELEGATE IN CONGRESS FROM THE TERRITORY OF THE VIRGIN ISLANDS; DR. THOMAS LAVEIST, ASSOCIATE PROFESSOR, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH; DR. LISA COOPER, ASSOCIATE PROFESSOR, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE; AND DR. ELENA RIOS, PRESIDENT, NATIONAL HISPANIC MEDICAL ASSOCIATION Mrs. Christensen. Thank you. Good afternoon, Chairman Souder, Ranking Member Cummings. Thank you for the opportunity to testify at what I feel is a very important hearing. The IOM report, which is at the center of this hearing, I think speaks for itself so I am not going to use my allotted time to recount the filings and I will summarize my written testimony. I particularly appreciate this hearing because this gives us an opportunity to have this information on an official record. As you know, we in the Congressional Black and Hispanic as well as the Asian Pacific Islander Caucuses held a hearing earlier this year on the report and the Department's response to the presence of health disparities. I am going to focus my remarks on issues surrounding the Department of Health and Human Services. Let me begin with the issue of diversity within the Department. We recognize and appreciate the work of Deputy Secretary Claude Allen and we have a great respect for his knowledge, understanding and his compassion about the health care disparities, but we do not feel that the Department's diversity goes deep enough. We are not convinced, for example, that the Office of Minority Health and the Office of the Secretary had direct influence on decisionmaking and policy setting across the Department. All of the offices of minority health must have their own budget, and their functions need to be institutionalized. Neither the Office of Minority Health or other programs critical to the elimination of disparities of health care, including the Agency for Health Care Quality and Research, which carries much of the mandate to develop policies to eliminate those disparities, have budgets that are reflective of a serious commitment. The Center for Minority and Disparity Health Research's budget has increased but we don't see any evidence that convinces us that center has full trans-authority for all minority and disparity research dollars at NIH or that it has adequate funding to support critical research infrastructure development or improvement at our minority health professions schools. The bottom line is that we are concerned that the Department's direction and focus has changed dramatically to one primarily of cost containment instead of one of providing the resources necessary to promote and restore good health, given that inequities exist, which if allowed to continue will threaten the very fabric of our Nation, and major investments must be a made up front immediately to level the playing field or we will never control health care costs, not to mention save lives, which is really of primary importance. Let me focus on a few issues, other issues. One of the important limitations, as you've heard, in the effort to eliminate disparities is the lack of data. A study commissioned by the Commonwealth Fund and done by the Summit Health Institute for Research and Education found that while the collection of data by race, ethnicity and language is legal, there is no uniform data collection within the Department of Health and Human Services. It is critical that the Secretary direct the Department to collect this data and, if need be, that Congress so direct the Secretary. One of the great barriers to appropriate health care is that of language differences between that of provider and patient. Patients are caught in between providers who are experiencing cuts that are driving them to close their offices and the need for the interpreters on the other hand. CMS must pay for those services, the services of the interpreter as well as restore the cuts and provider payments. This leads me to work force development. Much of the gap in health care for racial, ethnic and linguistic minorities in this country would be closed if we had more providers of the same language and same background. Yet education and training programs are cut in the proposed 2003 budget by more than $200 million. This needs to be restored, with emphasis on training providers of color. With regard to physicians of color already in practice, the programs of the Center for Medicare and Medicaid Services, their denials, their audits and their cuts in funding are driving an already marginalized group of practitioners out of business. The managed care system just makes the situation worse. We need a study to document what is happening to these physicians and CMS should require that all managed care organizations and group insurances provide services in medically underserved and high disparity communities and include the providers of those communities who are now systematically excluded. Subsidizing malpractice premiums to the degree that these providers care for patients covered by CMS also should be considered. Until the health care landscape is equal for all Americans all programs should be directed to place emphasis on areas where high disparities exist for the purposes of increased funding, for placement of National Health Service Corps physicians, and for community health centers, and also within the homeland security bioterrorism initiative. All areas of this country's public health infrastructure must be strong and intact or no one will be safe. The need for and the importance of universal coverage to reverse the inequities in health care cannot be overemphasized. Every year 83,000 people die for the specific reason that they lack insurance. Three more issues very briefly. A revolution must take place in strategies for addressing disease in our communities if we are to begin to see change. The most effective way to improve the health of our communities is by empowering the communities themselves through direct funding and technical assistance so that they can be their own agent of wellness. That is what we in the Congressional Black Caucus and Hispanic Caucus are attempting to do to the Minority HIV/AIDS Initiative, but under current departmental directives funding that used to be targeted to the community organizations within those communities of color just for this relatively small but critical program will no longer be so directed. And so we ask this committee to consider that the devastation of this tragic epidemic in communities of color constitutes a compelling government interest which meets the test of Adarand. We further request your assistance in restoring language to appropriately target the funding to build the capacity of the community and faith-based organizations our communities have long trusted and responded to so that we can bring this epidemic and all of the other disparities under control. A central issue is also the need for an effective Office of Civil Rights within the Department of Health and Human Services. In addition to a permanent director, this office also needs a significant funding increase for 2003. I would like to cite one important case which was the subject of testimony at our hearing which needs to be addressed. It's the Sandoval case in which the U.S. Supreme Court last year held that private individuals could not sue State agencies under Title IV of the 1964 Civil Rights Act for unintentional discrimination. Given the lengths to which they went, it is felt that the decision may signal a bad omen for the future of substantive agency rules condemning disparity impact under Title VI. Reversing the Sandoval decision is a high priority in eliminating racial and ethnic disparities in health care. Finally, the health care needs of American citizens in our territories whose Medicaid funding is capped and of the Native American peoples who suffer some of the greatest disparities in several areas must not be overlooked. This testimony just represents a few of the important concerns we have concerning the Department's policies and operations and the health care system nationwide. I really welcome and commend the subcommittee's interest and concern about this issue that is so vital to the community, communities which make up a significant portion of the population of this country. African Americans, Native Americans and other people of color, like all Americans, have the right to good health care but have long been denied. We are working with the members of this subcommittee to ensure complete access to all Americans for all Americans to quality health care. That is the only system that this country is worthy of. Thank you. [The prepared statement of Mrs. Christensen follows:] [GRAPHIC] [TIFF OMITTED] T6436.083 [GRAPHIC] [TIFF OMITTED] T6436.084 [GRAPHIC] [TIFF OMITTED] T6436.085 [GRAPHIC] [TIFF OMITTED] T6436.086 [GRAPHIC] [TIFF OMITTED] T6436.087 [GRAPHIC] [TIFF OMITTED] T6436.088 [GRAPHIC] [TIFF OMITTED] T6436.089 [GRAPHIC] [TIFF OMITTED] T6436.090 Mr. Souder. Thank you, Congresswoman Christensen. Maybe one of the things, you can work with Mr. Cummings and if there is additional materials from your caucus' hearing that you want to see put in this official hearing record, I would be happy to work with you. Mrs. Christensen. I'd appreciate being able to add for the record the testimony that we gave to the Labor-HHS Subcommittee of the Committee on Appropriations as well. I have another hearing to attend that I have to testify at. Mr. Souder. Thank you for taking the time and waiting for so long for us to get back. Mrs. Christensen. That's OK. Thank you. Mr. Souder. Let's see. Dr. Cooper, we'll go with you next. You're associate professor, Johns Hopkins School of Medicine, is that correct? Dr. Cooper. Mr. Chairman, Mr. Cummings, other honorable members of this committee, I am Lisa Cooper, M.D., Associate Professor of Medicine and of Health Policy and Management at Johns Hopkins University. I come before you today as a medical researcher, a primary care physician and a medical educator. Over the past 10 years with my colleagues I have conducted a series of studies investigating the issue of racial and ethnic disparities in access and quality of health care services. My work has focused on the role of the Patient- physician relationship in either perpetuating or ameliorating these disparities in health care. I am familiar with the IOM report, having contributed to the study as the author of a chapter on patient-provider communication. I would like to address three of the recommendations made in the IOM report: First, integrate cross- cultural education into the training of all current and future health professionals; second, increase the number of individuals from underrepresented minorities among health professionals; and, third, conduct further research to identify sources of ongoing racial and ethnic disparities and assess promising interventions. First, I strongly support the recommendation that the medical community integrate cross-cultural education into the training of all current and future health professionals. The evidence to support this recommendation comes from several studies showing that ethnic minority patients experience poorer quality technical and interpersonal care from physicians. African, Asian, and Hispanic Americans as well as Native American patients in the common race discordant relationship with their physicians report less involvement and less partnership in medical decisionmaking, less respect when receiving health care, lower levels of trust in physicians and lower levels of satisfaction with care. My colleagues and I found in a study of over 1800 managed care enrollees in Maryland, Virginia and the District of Columbia that ethnic minority patients reported their physicians were less likely to involve them in medical decisionmaking than white patients. Another recent study showed that white physicians are more likely to perceive African Americans and lower socioeconomic status patients negatively on several dimensions, including intelligence, the likelihood of engaging in high risk behavior, likelihood of adhering to medical advice, their ratings of affiliation or liking of these patients, and several personality attributes. While these perceptions are likely to be unconscious and unintentional, this study and several others mentioned earlier today suggests that the beliefs that physicians hold influence their interpretation of patients' symptoms, their interpersonal behavior when interacting with patients and ultimately their clinical decisionmaking. Therefore, it is essential that current and future health professionals at all levels receive training in intercultural communication. Legislation that mandates the inclusion of such programs into the curricula of health professional training programs supported by Federal funding such as residency and fellowship training would be particularly useful. Second, I support the recommendation made by the IOM report that we increase the number of individuals from underrepresented racial and ethnic minorities among health professionals. The evidence to support the need for more ethnic minority health professionals comes from several studies showing that African American and Hispanic American physicians are more likely than their counterparts to provide care for underserved populations. Additionally, we've heard before that racial and ethnic concordance between patients and providers is associated with higher levels of perceived quality of care, participation in care, and receipt of preventative care and even quality of care for some conditions, such as HIV. In the same study I mentioned to you earlier, conducted here in Maryland, Virginia and the District of Columbia, we found that patients who were seeing a race concordant physician felt more involved in decisionmaking. The active participation by patients in medical decisionmaking with physicians is an important marker of the quality of interpersonal care because it has been related to satisfaction, longevity of the patient- provider relationship, and better health outcomes such as diabetes and hypertension control. The goal of increasing ethnic minority health care professionals is to provide patients with more choices and access to a more diverse group of health professionals. I recommend--ask that you strongly consider supporting the continuation of policies in Federal funding to promote the training of health professionals from underrepresented minorities at all levels, including the provision of loan repayment mechanisms for physicians who provide care and conduct research to care for underserved populations. Finally, I strongly support the recommendation that the scientific community conduct additional research to identify sources of racial and ethnic disparities and to assess promising intervention strategies. Resources from the NIH and the AHRQ have allowed medical researchers to identify and explain sources of disparity and most recently to design and evaluate interventions to eliminate these disparities. These two agencies have provided the majority of funding for the studies conducted over the past two decades in this field. More well-designed interventions with rigorous evaluation are needed. As such, the AHRQ and the NIH will need a higher level of resources to assure that the research necessary to inform health policy as well as clinical practice is done in the most effective manner and that future researchers in the field of disparities receive appropriate research training. Finally, because access to high quality health care is an important determinant of health status, this research will likely play a pivotal role in improving the health status of the entire American public. Thank you. [The prepared statement of Dr. Cooper follows:] [GRAPHIC] [TIFF OMITTED] T6436.091 [GRAPHIC] [TIFF OMITTED] T6436.092 [GRAPHIC] [TIFF OMITTED] T6436.093 [GRAPHIC] [TIFF OMITTED] T6436.094 [GRAPHIC] [TIFF OMITTED] T6436.095 [GRAPHIC] [TIFF OMITTED] T6436.096 Mr. Souder. Thank you very much. Dr. Cooper, who is Associate Professor--no. Dr. Rios, excuse me, I am misreading here. You're President of the National Hispanic Medical Association. Is that correct? Dr. Rios. Yes. Mr. Souder. Are you a practicing physician or the Executive Director? Dr. Rios. Executive Director. Mr. Souder. Thank you. Is your mic on? Dr. Rios. Is it on? Chairman Souder, Congressman, HHS officials and guests, it is an honor to be here. The National Hispanic Medical Association represents licensed Hispanic physicians in the United States. The mission of NHMA is to improve the health of Hispanics. I also work as the CEO for the Hispanic-Serving Health Professions Schools, Inc., that represents 22 medical schools and three public health schools. The mission of this organization is to develop Hispanic students and faculty and research capacity to improve Hispanic health. And I would just like to say that I think I have to agree with the Congresswoman when she said we really do need universal access and that would be--I think that would go a long way to eliminate disparities in this country if we had access to health care. The Hispanic population right now is 14 percent of the U.S. population. By the year 2050 one out of every four Americans will be of Hispanic origin. We are the ethnic group in the country with the largest rates of uninsured. I know that the IOM report, however, discusses disparity not due to access related factors so I won't discuss insurance. But in the case of Hispanic patients we are challenged by language needs, literacy levels, lower levels of poverty and education, citizenship status, cultural beliefs and attitudes, family group decisionmaking, awareness of public health programs, or lack of awareness I should say, lack of awareness of how to even follow complex treatment regimens, how to read drug labels, where to go for further testing, x-rays or speciality care in our complicated health system. Our health system is the best in the world, but in order to be proud of that system this report challenges all of us to develop new strategies to improve the quality of health care delivery. And we like to address just some proposed strategies for HHS to continue to decrease rates in ethnic disparities in health care. And the first area, as has been mentioned, is diversity in medicine. The U.S. Federal Government has taken the lead to recruit and retain minority and disadvantaged health professional students since the 1960's, when it was recognized that it is a Federal Government role to develop programs that provide health care services for all vulnerable population groups in this country. Medicare for the elderly and disabled, Medicaid and community clinics for poor patients, and the National Health Service Corps and the Health Careers Opportunity Program for poor, disadvantaged or minority students so that they could become health professionals for their communities. In the 1980's, HHS further developed these programs by addressing the--by calling--by creating the Centers of Excellence and the Faculty Development Program for minority students at medical schools. Through its curricular efforts, the COEs impact cultural competencies of all their graduates. In addition, both of these programs have increased the number of minority faculty, although small, but they have increased the number of minority faculty that address research and curricular issues related to minority patients and communities. The literature demonstrates many examples of studies on the outcomes of minority health professionals serving a major need in the United States, mainly that they provide health and mental health care services for minority patients of their own ethnicity and for those on Medicaid and the uninsured. And there's definitely an economic impact by having minority health professionals in this country. HHS HRSA's Health Careers Opportunity Program and Centers of Excellence Program have proven track records of graduating two to three times more disadvantaged and minority students than the other health professions institutions in this country. However, for the second year in a row this administration has called for drastic down-sizing of these programs. We believe strongly that the IOM is a reminder for us with the changing demographics and continued immigration of Hispanics and the needs of all minority groups to recognize the critical need for minority physicians, and currently Hispanics are only 5 percent of America's doctors and only 2 percent of America's nurses, and both of these programs should be expanded with increased funding at the level requested by Congresswoman Donna Christensen at her testimony to the appropriations hearing. We also propose a new strategy that these programs be expanded into public-private partnerships with the medical schools, led by HRSA. The medical schools have institutionalized recruitment and retention programs. They have minority affairs offices. They have staff. But they should be required to provide more matching funds and fund-raising efforts to increase the support for these programs. We support the request from the caucuses again to increase the support from the Federal Government, also. And why shouldn't a recruitment program be linked to academic enrichment in middle schools and grammar schools and colleges through scholarship incentive programs, for example, that could be privatized? Scholarships could be linked to the students who would be linked to programs developed at certain schools and regional consortia. Why shouldn't businesses, especially the HMOs, hospitals, pharmaceutical companies, medical suppliers and medical groups that are employers and business partners who directly benefit from their linkages with physicians be fiscal partners in the education process of future physicians? We also recommend that there should be collection of data of the--about the alumni from these programs and link their location of practice to medically underserved areas or health professional shortage areas, as does the community clinic and the National Health Service Corps program. Furthermore, Medicare GME funding for teaching hospitals should be linked with the policy focus to provide incentives to produce minority physicians and minority programming. There should be loan repayment for faculty, and I think that physicians should be encouraged to sign up for the National Health Service Corps more than we are now in terms of minority physicians. President Bush's Medical Reserve Corps is another example of an effort where we could get more volunteers to work through that effort to help recruit younger students in doctor's communities. Cross-cultural education was mentioned by my colleague. I won't go through that, just to say that it is very important because we have so few minority doctors in this country that the majority of doctors need to have cultural competency training in medical schools, and in fact the accreditation body for medical schools in this country just mandated that cross- cultural education be a requirement for medical schools so that the future generation of doctors in this country can better know how to communicate and understand and respect their patients. We also recommend the funding for HRSA for the Cultural Competence Curriculum Demonstration Grants that were part of the Health Care Fairness Act that created the new national Center for Minority Health and Health Disparities Committee. They were never funded. Also, the Agency for Health Care Research and Quality and the Centers for Medicare and Medicaid services should also include cultural competence training not only of the health providers, the doctors, but the health staff, the programs that they support. Third thing is language services, and I think that it's just important to realize that there are so many people that speak other languages in this country and they do need and deserve to have access to the health care system and they do deserve to be able to communicate with their providers. I think that we understand the importance especially of Spanish speakers in this country, the increasing number of Spanish speakers and that we do know that the White House Office of Management and Budget just concluded its study on the implementation of the Limited English Proficiency Executive Order and said that the benefits seem to outweigh the costs since language services improve access to and can increase effectiveness and distribution of public health programs. Moreover, language services will substantially improve the health and quality of life of LEP individuals and their families. We propose that HHS support demonstration programs in language services to develop the reimbursement models needed through programs that exist right now at HRSA, the community clinics at SAMHSA, the drug treatment centers, the centers for Medicare and Medicaid services through Medicare and Medicaid. Interpreter services should be developed not only for bilingual staff and bilingual providers but for consultant interpreters. That should be developed as new auxiliary health positions with certification and training programs, and Spanish language training for providers through CME programs and for medical students should be supported significantly in targeted markets through demonstration projects. There really is a critical need to do this now to prepare for even more Spanish speakers in the future in this country. I also think there could be a new program for managed care partnerships in targeted States that could be used as incentives to get Medicare programs to expand services to the Hispanic elderly. All of HHS prevention literature needs to be in different languages and media. Both English and Spanish TV, radio, Internet and print needs to be partnered by HHS to start developing targeted public health messages. Now just a couple of systemic strategies that this report leads us to think about. The Hispanic-serving health profession schools has a project with the CDC to develop its faculty data bases. There has never been an attempt to identify doctors in this country who are involved in minority research, and I would imagine that historically black colleges and universities have done a great job in knowing that about their own faculty but I think that for the Hispanic community in this country this is the first time that we are attempting to identify resources, our human capital resources among our own faculty to do research on Hispanic health. The National Hispanic Medical Association has developed a leadership program for doctors, and this is another area that this report leads us to believe that HHS needs to start thinking about supporting leadership, not only within its ranks but the leadership of minority communities so that they understand how to access or how to improve access programs, outreach programs, enrollment programs and that we have middle managers as well as physicians learn how to work hand in hand with the government at the Federal and State level in matters of leadership development. We also have for future data collection and research, and this is the last set of recommendations, there is a real need for collaboration among the research agencies at HHS on the importance of minority research, cultural competence research, and I think, as was stated earlier, especially community-based research where we include the community in helping to design and develop new strategies and interventions and study those hand in hand with researchers and academic institutions. I think Dr. Ruffin mentioned earlier about that cultural competence research in the future and Dr. Clancy talked about the EXCEED programs, and these are examples of programs that are very much needed to be expanded for research. The National Hispanic Medical Association has established a foundation, the National Hispanic Health Foundation, and we soon will be developing plans to do health services research targeted for Hispanic, understanding Hispanic community issues. We will be working with the New York University's Wagner Graduate School of Public Service, and we look forward to helping to develop more knowledge about the Hispanic community, and I think that's one of the wakeup calls of this report is that we don't know enough about interventions and strategies. We know that there's a huge, huge problem and it's ironic that on the verge of a huge demographic change in this country where everybody is going to realize that minority health is important and that main stream America has recognized that minority health is important we need to do something about it and we're here to help. So we're here to help with again reaching out to our communities and being a link to get more information and more leaders for the government. [The prepared statement of Dr. Rios follows:] [GRAPHIC] [TIFF OMITTED] T6436.097 [GRAPHIC] [TIFF OMITTED] T6436.098 [GRAPHIC] [TIFF OMITTED] T6436.099 [GRAPHIC] [TIFF OMITTED] T6436.100 [GRAPHIC] [TIFF OMITTED] T6436.101 [GRAPHIC] [TIFF OMITTED] T6436.102 [GRAPHIC] [TIFF OMITTED] T6436.103 [GRAPHIC] [TIFF OMITTED] T6436.104 Mr. Souder. Thank you for your testimony. We've been joined by Dr. Thomas LaVeist. I need to swear you in. If you'll stand. The subcommittee as an oversight committee requires it. [Witness sworn.] Mr. Souder. Let the record show that the witness responded in the affirmative. Thank you for joining us and we'll let you have 5 minutes for your testimony and we'll insert anything you don't get covered into the record or any additional materials. Mr. LaVeist. Thank you. I beg your forgiveness for returning late from recess. Mr. Chairman, honorable members, thank you for inviting me to participate in this important hearing. The recently released Institute of Medicine's report on racial disparities and health care summarizes decades of research that has not always received the attention that it deserved. I have devoted my career to further understanding the issues of racial disparities in health, and I am pleased by the response that has come from this report. I am encouraged that later this year Johns Hopkins University along with Morgan State University will announce the creation of the Center for Health Disparities Studies, and the goal of that center will be to bring together--bring to bear the resources of both institutions to address this very important problem. According to the Census Bureau, in the coming decades American racial and ethnic minorities will be an increasing proportion of the national population and eventually become a majority. As such, the health profile of the country will increasingly become reflective of its minority population. The United States already has a surprisingly low international standing with regard to health status. We are already No. 17 in female life expectancy and No. 26 in the world in infant mortality. This is only one spot above Cuba. Without a reduction in and elimination of health disparities our international standing in terms of health will most likely be even lower in the coming decades. This will have an important negative economic impact as well in terms of lost wages and productivity due to disability. And the impact on the Federal and State budgets is predictable, increasing Medicare and Medicaid costs, and we can't ignore the impact that increasing health care costs will have on the private sector. While the IOM report is important, this is not the first published report documenting disparities and even discrimination in health care. This is not even the first such report written by the IOM. So why am I so hopeful that this time the issue will not again lose momentum and exit the national agenda? The reason for my optimism is that I believe there is the potential to establish a national infrastructure to address race disparities in health. Creation of the National Center for Minority Health and Health Disparities is among the most important improvements to our Nation's health care infrastructure in decades. As one who has been conducting research on minority health and health disparities for many years, I want to take this opportunity to thank Congress for its leadership in creating this center. This new entity will play a central role in ensuring that the issue of minority health and ill health remain on the national agenda. But we must not stop there. American public health and medical researchers have sustained a steady march toward the furtherance of our understanding of the causes of premature death, ill health and preventable disability. But while we have been leaders in furthering knowledge and health status and curing disease, we have been less attentive and some might even say accepting of pervasive disparities in health. Why is it that American minorities live sicker and die younger? Certainly the answer is complex and elusive, but there are a few things that we do know. We know that it is unlikely that the answer lies in biology and is exceedingly unlikely that a solution will come from genomics. Likewise, programs such as Take a Loved One to the Doctor Day, which was recently proposed by the Secretary of Health and Human Services, misses the mark and will have little efficacy. Increasing the number of minority health care providers is needed, but this alone will not solve the problem. The weight of the evidence I believe indicates that the causes of persistent and pervasive racial disparities in health lie in the actions and inactions of individuals and the inequitable outcomes within health care organizations and health systems. Health care lags behind other government- regulated industries in that health care has not addressed racial discrimination since the desegregation of hospitals. Housing, labor, education, criminal justice, these areas all have ongoing systems in place to monitor, measure and sanction documented discrimination. In contrast, there are many hospitals that do not even collect data on patients' race. Why? Well, my contribution to the IOM report was to outline the basic parameters of the development of a civil rights monitoring program in health care. Monitoring systems are not unprecedented in health care. There are existing monitoring programs for health care quality, patient satisfaction, and there are report cards on health systems. A health care discrimination monitoring and enforcement system similar to efforts in housing will not likely be the solution to disparities in health care, nor will it solve all health access problems. However, such a system will help us to move toward equity in health care equality and likely reduce disparities in health care outcomes and improve health status. Thank you. [The prepared statement of Dr. LaVeist follows:] [GRAPHIC] [TIFF OMITTED] T6436.105 [GRAPHIC] [TIFF OMITTED] T6436.106 [GRAPHIC] [TIFF OMITTED] T6436.107 Mr. Souder. I want to thank each of the witnesses once again for your patience. This has been a long afternoon for your testimony, and working with it, I would strongly encourage each of you as you work with this and as you work with the agencies and with Congress to make sure--I don't think any of us would deny regardless what political party, maybe some are less inclined, that discrimination in fact occurs. But in order to address it we need to know where it is discrimination based on race or ethnic backgrounds and where it's discrimination based on income, cultural, education, language, and to make sure that where possible, it may include marriage differentials, in trying to figure out how best to address where the root problems are in the differentials we have to make sure we have the right mix of scientific data. One thing is that you have to collect it. I think that there are several other things that I want to make sure that I put in the record. I know one of the problems with medical coverage in a lot of our urban areas has to do with the medical malpractice insurance. And we have to address that question because the cost disparity in those places for a physician to come in is huge, that over the years--I mean there are just tremendously underserved and that's one of the cost pressures of any doctor looking at coming in. We need to be fair to the patients and at the same time not have that be a distraction. I think another kind of fundamental thing that I've seen in the emergency rooms, in particular, is the bill collection process, where the hospital collects different from the doctor, which collects different from the other testing procedures, is chaotic no matter what your background is. If you're trying to manage a limited amount of income to try to figure that out and think you paid the bill then another bill comes, just at a gut level having gone through different things in the emergency room and talking to different individuals, this is a much bigger problem than is acknowledged because the bill collection percentage is really low in some areas. And it's why hospitals financially are moving more toward suburban markets and they find a financial disincentive in some of the doctors. We have to figure out where those gaps are in the system and how to address those gaps, because if we aren't reflecting what is actually occurring at the grass roots level it becomes very difficult even while we may be able to force someone by saying, which I support, if you're going to get a student loan you will underwrite a certain portion to go to a low income-served area. The second they fill their requirement in 3 years they're gone. If we can't make it so they can figure out how to survive long term, we need to address those questions. I have a couple of specific questions for Dr. Cooper and then if any of you want to comment on the remarks that I made. I thought it was interesting and logical that primary care patients in race concordant relationships rated their physicians as being more participatory than those in race discordant. Were the statistics at a level enough to be statistically reliable? Dr. Cooper. Definitely they were. In fact, in the study that I mentioned that took place in this area in Maryland, Virginia and the District of Columbia the differences between patients and race concordant and discordant relationships were of a magnitude such that they predicted at least a 10 percent increased likelihood that a patient would disenroll from the physician's practice over 1 year. So it was statistically significant, but also likely to be clinically significant as well. Mr. Souder. Is that true in African American, Hispanic, Asian and all groups? Dr. Cooper. That was in all groups that we looked at. Mr. Souder. Are you able or were you able to in any way separate that statistic to see how much of it was language and how much of it was--in other words, let me give you an example in veterans hospitals. Veterans prefer to go in many cases to a veterans hospital because they perceive that they're treated differently, different respect and some of them are what I would call maybe psychological variables which are still real. Others are actual barriers because of language questions. Dr. Cooper. We actually did not ask about language. You know, all of these patients were proficient enough in English to respond to the survey. So it would suggest that these people were not people who were experiencing extreme language difficulty. There's been other work that shows that minority patients will say that they prefer a physician of their same race or ethnic group and that will occur aside from language similarity, that language concordance is something that contributes to that, but not totally. Mr. Souder. Do you find, and I know this an explosive question, I'm just asking to see whether the data reflected this--is this predominantly an anglo ethnic or would this apply to a Hispanic group with a Hispanic--with a black doctor, an Asian group with a Hispanic doctor? Dr. Cooper. Right. We actually looked at physicians of different races to see where the stronger effect was, and we found that within each race group the physicians who were seeing patients of their same race were rated more highly with the exception of Hispanic physicians, where we didn't achieve statistical significance but we had a much smaller number of Hispanic physicians in the sample. So it seems it's not a finding that is limited to one specific ethnic group, but that all ethnic groups, patients of all ethnic groups will express this increased satisfaction or partnership when there's a similar race physician, which leads us to believe that there's something about the relationship and the rapport that may have something to do with cultural similarities or similar social experiences, something else that we haven't quite captured, some trust between people that is based on, you know, just comfort level and expectations of being understood and treated well. So what we'd like to do is see what we can learn from this. We think it suggests that we need more diversity among health professionals, but it also suggests that maybe there's something we can learn from these same-race relationships. Is there something that goes on in those relationships that we can use to teach other people so that when they're relating cross- culturally and interculturally that they can emulate those same behaviors and attitudes. Mr. Souder. It's really an important point because I think while we'll try to continue and we need to continue to try to recruit more minority people into the health care, the truth is particularly when you get into a mid-sized city as opposed to large city the base of the sub-communities are not big enough with which to sustain all the diversity. For example, in Ft. Wayne, which is 200,000, 300 in the metro area, in the south side of Ft. Wayne in the community health center, which has historically been African American--I think it's now down to about 25 percent, maybe 40 percent Hispanic, another 15 percent Burmese and another 5 to 10 percent Bosnian with hardly any Anglo in it, and yet it's not big enough to sustain a doctor in each one of those subgroups and a nurse in each of those subgroups. So we have to figure out how to cross-train because even if we expand it it's not clear that a minority person who is in that area will be of the minority, particularly since neighborhoods shift. One of the areas that for some reason we have whole lot of Bosnians who came into my area and we have the largest Burmese population in the United States. It was 400, now there's over 2000. So when they move that a neighborhood it changed substantially who would be providing the health care to them. And they don't--many of them don't speak that much English. And it is--we've never had a Burmese population before, so it's kind of a new phenomena that the whole community is working through. The Mexican immigration is easier and Central and South American immigration because we're dealing with languages but in some of my school districts they have 22 languages in rural Indiana. So you know that this problem is becoming increasingly challenging all over the country. Dr. Cooper. I think what we're trying to do is to learn exactly what cultural competence is. What does that mean? And are there some generic skills that the students and health professionals need to have in order to interact effectively regardless of who they're interacting with, you know. Because-- and I think we cannot over simplify the fact that a person is from the same race or ethnic group doesn't mean that they're necessarily going to hold all the same beliefs and values as well. So I think we're trying to understand more from our research what this cultural competence phenomenon is so that we can actually teach it in a more effective way. And we need to teach it and also to evaluate how our teaching is impacting on care and our outcomes. Mr. Souder. Mr. Cummings. Mr. Cummings. Dr. LaVeist, do you--how much faith do you have in this National Center for Minority Health? Mr. LaVeist. I do think it's very important. I do have faith in it, because what that center does is tries to cut across the various institutions at NIH. NIH is set up in a disease specific way. But the issue of race disparity is not disease specific, it's not so much cancer or heart disease or stroke, it's all that. I think a center that cuts across the various health outcome mandates of those institutes I think is the right configuration. My faith is I guess entrusted in--my faith is operating under the assumption that it will continue to be funded at an appropriate level and as such be able to do things like develop these research centers and fund these centers appropriately so that these centers can continue to do the kind of research that needs to be done. Mr. Cummings. You were here a little bit earlier and you heard the testimony of how certain things were being cut back with regard to the---- Mr. LaVeist. HRQ. Mr. Cummings. Yeah. And how that seems to fly in the face of all the things that we're talking about here today. Did you have a comment on that, Dr. Rios, on what I just said? Dr. Rios. Oh, sure. I couldn't agree with you more. I think it is a time, a very difficult time right now when the Federal Government is committed to healthy people 2010, which is still another 8, 9 years away. We've got all the States involved with trying to focus in on collecting race data now, collecting subgroup data for Hispanics. Now we have a new census, a 2000 census, that shows us that we've got markets in different countries, as the chairman alluded to, markets where we haven't seen minority populations live. We have a health care awareness of the need for language and culture to make a quality health care. And in spite of that, the funding for I think what is very important, research and preparing for the future, is being targeted for major cuts. And the health professions too, I have to throw that in. I think that we need to think about how to have a cross-cutting approach to HHS when we talk about disparities. And there are things that do work. There are programs that are working that have proven successful for increasing minority health. Only nobody's ever looked at them together. The National Health Service Corps that you mentioned, there should be a more targeted approach to people that come from certain communities to--and I'm from California, and in California there's a State-based, a State Health Service Corps Program, So that the doctors would pay back their student loans but stay in the same State. And there was more of a chance at that time doctors would go working in community clinics and certain communities and staying in those States because they're from the area. Mr. Cummings. Dr. Cooper, when you--you know, I was talking about this study on the radio in Baltimore, and I was trying to figure out what the listening audience could do themselves because the report sounded so bleak. And when I look at the funding situation, I mean I'm trying to figure out what do you say to a patient or people who--because there are a lot of people who are sick and don't even know it. And I mean, do you tell them to go and get--I'm not trying to take the weight off the government because we're supposed to do what we're supposed to do, but in the meantime what do you say to a patient. If you had a patient that had read this report and understood it, and the patient says, well, what advice do you have for me and for my family, I mean, because according to the report you got insurance, I mean apparently you know how to get to a doctor, these people, and I'm talking about as far as the study is concerned, I mean what do you say to them? They can't just go up to say, look, are you a racist or what? So what do you say? What would you as a doctor say? Dr. Cooper. I think what I try to say to my patients is, well, first of all, I try to ascertain from them what their level of interest is in advocating for their own health and try to encourage them to become more active in this, engaging in more healthy life-style changes and in healthy behaviors. But I also encourage them to become more involved in learning about health and encourage them to ask questions when they don't understand. I think this is part of what we're talking about when we say improving intercultural communication. We're talking about cultural sensitivity and reducing stereotyping behavior and bias, but we're also talking about just using good communication skills, which will allow people to express what their concerns are. So just asking people what's your understanding of what's wrong with you and trying to assess where they are with that and can you tell me why you think you have kidney failure and what do you think would help in this situation. And so trying to understand what people's own understanding of their illness is and what they think would work for them and then working with them based on their own social and family situation, but trying to get them really engaged in the process, because we know that's the only thing that's going to allow people to make changes in their behavior. Mr. Cummings. Do you say to the person, the African American person who this report says has the 3.6 times chance of having an amputation if he's got diabetes--I mean what do you say to that person when they come to you and say, Doc, I read this report, and it's a lady, and she says I love my legs but now they're saying I've got it? And this is very real. Dr. Cooper. I am concerned about the impact of this report on the doctor-patient relationship. I think it's very important that we're looking at these problems, but I also am concerned that the way that the message is portrayed is not such that it causes more distrust between patients and providers. I think what I would say to people is that you know, I think the majority of health professionals don't go into this field so that they can discriminate against people, that a lot of these people are well-meaning people that have good intentions, and what it is is that people are just not aware of their own biases. And so although I believe the burden of responsibility is on health professionals first and foremost, I think that patients can play a role if they're more informed about what is going on and they know what is appropriate for them. So if they can get information, ask for someone who is an educator or case manager to explain to them what should I be getting if I'm a diabetic patient, what kind of treatment should I be receiving that I'm not receiving, you know. Am I on the right medication that I should be on? Am I on the right dose? What should I be asking my doctor to help me do so that I don't end up with an amputation? And letting them know that they do have a right to ask those questions and to request, you know, certain things. Mr. Cummings. But tomorrow my leg is going to be amputated. My leg is going to be amputated, Doctor, and I know that as a black person I have a four times, almost four times greater chance. I mean that's the rest of their life you're talking about, quality of life you're talking about, you know, having to go around this a wheelchair. See, and that's what make the report so--and I agree with you. I'm concerned about the other end of it, too. But when these people call me and say what are we supposed to do, you know, that kind of stuff is just so wrenching. I think government has to, we've got to do more. We've got to find ways--I've often said, and I'm sure the chairman agrees with me, we've got to spend the people's tax dollars effectively and efficiently but we've got to find ways in that mode of effective and efficiency, we've got to find ways to try to prevent some of the catastrophes that this report says are happening every minute of almost every day. Dr. Cooper. And I think it's going to have to take place on several levels, you know, like the chairman mentioned. Financial incentives for providers need to be changed. I think from the patient perspective, doing everything they can, having them know that they do have a right to question what's being done to them and that they can request a second opinion, they can bring in a family member, or they can call someone else who they know who might be more familiar with the health care system and ask their opinion as well, that they're entitled to that. I think if there's anything we can do it is to educate the public that this is a problem and that you do have a right to question this and to ask for the best quality health care because it's available here in America. It is here and it's a question of actually advocating more actively for it whenever possible. So, but again I feel like that we can educate and activate people up to a point, but really the burden is on the system and on the professionals to take the lead in that role. Mr. Cummings. Finally, there were three things that you all would want us to do, Dr. Rios. What would those three things be? I mean top priority. If the Congress said there are three things that we're going to do, we may not be able to do all this other stuff that is recommended, but the things that come under our purview, what would be the three top things off the top that you would want to see us do? Dr. Rios. No. 1 is universal access. I think if we can have public education, and this system may not be the best, public schools in certain cities, depending on the teachers and the curriculum, but we certainly have an opportunity for education. And in this country we don't have an opportunity for health care. That's part of the big problem for disadvantaged and immigrants and Hispanics and other minorities. That's No. 1. No. 2 I think is more research that's community based and targeted approaches and intervention so you can measure and understand with a small study what works, what doesn't work. The interpreter services, right now the Robert Wood Johnson Foundation just started the new project of La Muz Huntos to do that. They're looking at cities where it's an emerging problem to understand how to work with doctors that have never worked with Spanish speaking patients before. So I think I know we need community based research, targeted, demonstration models, with minority consumers and minority providers working with the government. And the third thing is we need the minority doctors, because what we don't have is the minority physicians to document the cultural competence and the best practices. For years we've had doctors working in small mom and pop private clinics, private offices. I am from the East L.A. area, they're still there, volume cash paying patients. It's a whole underground market. There's no licensing from--I mean there's no data collection from the State because the State only collects from licensed clinic, licensed hospitals, licensed nursing homes. These are private businesses. Managed care doesn't touch the underground that exists in our minority communities. Doctors provide care because there's a demand. But there's no documentation of what are the best practices and how those doctors do get those patients, and generations after generations of families after families coming back to the same doctors. And that's the quality care that we need to understand and meld with our academic health centers, where a lot of minority patients go there, you know, because there's training going on of young residents. Mr. Cummings. Thank you very much. Mr. Souder. I want to thank you all for participating and thank Mr. Cummings for seeking this hearing and working with us. I found it very informative, and one of the primary reasons we did this is we know we're never going to fully fix our health care system and people are always going to complain and the hopes and dreams of a perfect health care system outstrip our ability to pay for it and the new inventions of everything from drugs to facilities that are unimaginable at this point. We don't even know what's going to be invented tomorrow, and our expectations and the reality of it need to be addressed. We also know we have huge immigration questions in this country, that we've always had them, but right now they're of particular attention and we have to work that through, which is a subpart of what you're doing. I felt this hearing was also especially important because whether or not we get more than 59 percent happy with the health care system may or may not be achievable long term, but what we do know is there shouldn't be a 20 percent disparity. And even in those statistics, 59 to 50 and 40 something to 40, between African American and non-African American, for example, is not right. And even if the gap is closing we need to be concentrating on whatever satisfaction level we can get as a society. The gaps inside it should be minimal, and that's ultimately one of the goals of Congress. And we appreciate your help with that and Mr. Cummings' leadership. With that, our hearing stands adjourned. 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