1. Discrimination in the Health Care System Discrimination in the Health Care System Separate and Unequal Maxine Golub, MPH Senior Vice President The Institute for Urban Family Health Project Administrator Bronx Health REACH 19th National Conference on Chronic Disease Prevention and Control March 2, 2005

2. OutlineOutline 1.Bronx Health REACH Coalition 2.Seven Point Advocacy Agenda 3.Barriers to Health Care

3. BackgroundBackground  The mission of the Bronx Health REACH Coalition is to eliminate racial and ethnic disparities in health outcomes in the southwest Bronx by creating a movement of individuals, agencies, organizations, and communities, working together, sharing resources, expertise, information and services  The initiative is funded by grants from the Centers for Disease Control and the New York State Department of Health  The service area covers 4 zip codes – 10452, 10453, 10456 and 10457 in the southwest Bronx

4. Bronx Health REACH Coalition Members  The Coalition consists of more than 30 groups. They include:  Community-based social service organizations  Health care providers  An academic research center  Non-profit housing groups  Economic development organization  After-school program  15 faith-based organizations  Advocacy groups for diabetes  Non-profit legal groups

5. Bronx Health REACH Initiatives  Faith-Based Outreach Initiative  Fitness and Nutrition Initiatives  Grocer & Restaurant Outreach (Healthy Hearts)  Community Health Advocacy Initiative  “Got Sugar?” Diabetes Education Program  Public Health Education Campaign  Cultivating Change in the Provider Community  Action Committee - Legal and Regulatory Initiative

6. Bronx Health REACH Statewide Advocacy Agenda Bronx Health REACH Statewide Advocacy Agenda

7. Seven Point Advocacy Agenda 1.End discrimination in health care facilities 2.Create a more diverse healthcare workforce 3.Provide health insurance for all 4.Ensure culturally and linguistically competent care 5.Expand funds for public health education 6.Ensure accountability for charity care funds 7.End environmental racism

8. Discrimination in Health Care: Separate and Unequal 1. Maldistribution of insurance coverage by race 2. Segregation of the poor and uninsured (predominantly people of color) into different institutions 3.Segregation into different care systems within institutions, especially in our major teaching hospitals 4. Failure of Managed Care to create open access 5. Institutional subsidies (Bad Debt and Charity Care, Indigent Care Pools) which fail to provide equitable access to care 6. Inequities in payment by the Federal Government

9. - 1 - Maldistribution of Insurance Coverage by Race

10. % Uninsured by Race

11. % Publicly Insured and Uninsured by Race

12. - 2 - Segregation of the Poor and Uninsured into Different Institutions

13. Discharges by Expected Source of Payment (SPARCS Table IX 2001)

14. NYC Public Hospitals bear the higher percentage of patients that are uninsured and Medicaid (SPARCS Table IX 2001) Public Hospitals Private Hospitals

15. Jacobi (public) v. Montefiore Weiler (Distance: 2 blocks) Source: SPARCS 2001 Table IX

16. North Central Bronx (public) v. Montefiore Moses (Distance: Contiguous) Source: SPARCS 2001 Table IX

17. Bellevue (public) v. NYU (Distance: 1 Block) Source: SPARCS 2001 Table IX

18. - 3 - Segregation of the Poor and Uninsured into Different Systems of Care within Institutions

19. Results of Hospital Survey   FACULTY PRACTICE AND CLINIC DISPARITIES   Almost all Academic Medical Centers we looked at operate two separate systems of care – largely based upon the patient’s insurance:   Sometimes they operate in the same physical space at different times/days and sometimes in different spaces – but always with different models of care

20. The “Faculty Practice” Model

21. The “Clinic” Model

22. - 4 - Failure of Managed Care to Provide Open Access

23.  NY State Medicaid, Child Health Plus and Family Health Plus contracts all require that …  “All training sites must deliver the same standard of care to all patients irrespective of payer. Training sites must integrate the care of Medicaid, uninsured and private patients in the same settings.” NYS Managed Care Contract Language forbids segregation based on insurance status….. but remains unenforced.

24. Results of Hospital Survey  MANAGED CARE can limit access when it is supposed to do the opposite  Each hospital participates in a limited number of Medicaid, CHP, and FHP programs  Specialty care may not be accessible in a neighborhood hospital if a patient belongs to a managed care plan that has not contracted with that hospital  Many hospitals contracted with only a few plans. The Children’s Hospital of Montefiore, for example, participates in only 4 of the 17 health plans licensed in the community

25. - 5 - Institutional Subsidies (Bad Debt and Charity Care, and Indigent Care Pools) Fail to Provide Equitable Access to Care

26. Institutional Subsidies  New York State hospitals received $847 million in 2002 to cover the costs of bad debt and charity care, but does not allow individuals to seek care using these funds  The state has no mechanism to allocate funds to assure that funds are being used to provide services to those who are underinsured or uninsured, the majority of whom are people of color  Hospitals are permitted to bill patients full charges and sue for payment while still collecting enormous subsidies

27. - 6 - Inequitable Payment for Medicaid Services by the Federal and State Governments

28. Inequities in Government Payment for Health Care Services The Federal Government has two major health care programs - Medicare for the elderly and disabled and Medicaid for the poor New Pt Comp Consult Estab Pt F/U

29. 1998 Medicaid Payments per Recipient, by Race

30. CONCLUSIONSCONCLUSIONS  There are gross inequities in the delivery of care  Inequities start with differential insurance coverage  Institutions sort patients by insurance, resulting in de facto racial sorting  We cannot eliminate racial disparities by providing inferior care to our patients  We cannot sort patients into different institutions, provide them different systems of care with different quality and then expect the same health outcomes “Be the change you wish to see in the world.” - Gandhi - Gandhi

31. REACH Recommendations 1.Develop enforcement mechanisms through the Patient Bill of Rights and Certificate of Need (CON) Process 2.Equalize reimbursement rates to create access to equal quality of care for Medicaid recipients and the uninsured 3.Mandate the collection of race data through the establishment of a Commissioner led collection committee