Arlee Gist, B.A., Deputy Director

Offi ce of Minority Health and Health Disparities

Maryland Department of Health and Mental Hygiene

February 21, 2013

AFRICAN AMERICANSENVIRONMENTAL JUSTICE AND

HEALTH DISPARITIES

Maryland Department of Natural Resources 2013Black History Month Program

What is a health disparity?“A higher burden of illness, injury, disability, or mortality experienced by one population group in relation to a reference group; and a healthcare disparity can be described as differences in, for example, coverage, access, or quality of care.” **

* The Henry J. Kaiser Family Foundation, Policy challenges and opportunities in closing the racial/ethnic divide in health care. Race, ethnicity, and health care issue brief. 2005, The Henry J. Kaiser Family Foundation: Washington, D.C.** National Institutes of Health (US). NIH strategic research plan to reduce and ultimately eliminate health disparities; 2000 October 6.

What is a disparity?“…Differences in the incidence, prevalence,

mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” *

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Historic Perspective1895 – Booker T. Washington at Atlanta Exposition Meeting: discussed deficiencies in Negro health care

1899 – W.E.B. Dubois “The Philadelphia Negro: A Social Study”: a sociological study of Negroes including health

1903 – W.E.B. Dubois “Souls of Black Folk”: discussed declining health of Negroes post slavery

1968 –“Kerner Commission Report”: speaks of gains in Black American’s social welfare, however health inequalities remain severe and troubling

1976 – National Medical Association: met in Washington, D.C. and discussed access, morbidity and mortality disparities between Blacks and Whites

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Historic Perspective (Continued)1980 – Black Congress on Health Law and Economics: met in Dallas, Texas and discussed strategies for bridging health care gaps between Blacks and Whites

1985 – Report of the HHS Secretary’s Task Force on Black and Minority Health (Heckler-Malone): identified the continuing existence of health disparities

1999 – IOM Report: “Unequal Burden of Cancer”, Alfred Haynes & Brian Smedley, Editors: cancer as experienced by ethnic minorities and medically underserved

2002 – IOM Report: Confronting Racial and Ethnic Disparities in Health Care: Brian Smedley, Adrienne Stith, Alan Nelson, Editors: race and ethnicity remain as significant predictors of health care quality

National Attention on Health Disparities

Maryland Attention on Addressing Health Disparities

Report of the Governor’s Commission on Problems Affecting the Negro Population, 1943

• Found health disparities in birth rates and death rates for minority populations compared to the White population;

• Found that there was a disparity in the number of hospital beds available to minorities compared to whites;

• Noted that environmental factors such as inadequate diet, occupational hazards, and poor housing conditions may lower their resistance to infection and increase the likelihood of disease.

Healy, J.P., Report of the Governor's Commission on Problems Affecting the Negro Population. 1943, African-American Department.

Now is the TimeAn Action Agenda for Improving Black and Minority Health in Maryland, 1987

• A Governor appointed 27 member Commission was charged with conducting “a thorough examination of the programs and laws relating to the health status of Maryland’s minority citizens”;

• Focused on cardiovascular disease, AIDS, cancer, maternal and child health, homicide, aging, substance abuse, mental health, medical indigency, and minority health manpower.

Maryland Department of Health and Mental Hygiene, Now is the Time: An Action Agenda for Improving Black and Minority Health in Maryland. The Final Report of the Maryland Governor's Commission on Black and Minority Health. 1987, Baltimore, MD

Report of The Governor’s Commission on Black Males, 1993

• Studied the nature and extent of problems in employment, health care, criminal justice, and education and the effect these problems have on African-American males in Maryland.

• Recommendations include:• Approaches to such extensive problems of health care and

insurance must be comprehensive;• Address the need for better coordination and outreach within

existing programs;• Address the need for development of additional programs aimed

at African American males that include new ways of creating health environment, lifestyle, and positive changes in health indicators.

The Maryland State Governor's Commission on Black Males, Report of the Governor's Commission on Black Males. Maryland's African-American Males Health, Education, Employment and Economic Development, and Criminal Justice. 1993: Annapolis, MD.

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Minority Population in Maryland, 2010

All Ethnicity Non-Hispanic Hispanic

White 3,359,284 58.2% 3,157,958 54.7% 201,326 3.5%

Non-White 2,414,268 41.8% 2,144,962 37.2% 269,306 4.7%

Black 1,700,298 29.4% 1,674,229 26,069

Asian Asian 318,853 5.5% 316,694 2,159

3,157 0.1% 2,412 745

American Indian 20,420 0.4% 13,815 6,605

206,832 3.6% 11,972 194,860

164,708 2.9% 125,840 38,868

MD Total 5,773,552 100.0% 5,302,920 91.8% 470,632 8.2%

Race Alone

Hawaiian/ Pac Isle

Two or More Races

Some Other Race

Maryland Population, 2010 U.S. Census by Race and Ethnicity (45.3%) Minority

Source: 2010 Census Demographic Profiles, Department of Planning, Projections and Data Analysis/State Data Center, May 2011

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Health Disparities in Maryland • Compared to Whites, the Black or African American death

rates for the period of 2007-2009 were:•1.2 times higher for heart disease•1.2 times higher for cancer•1.3 times higher for stroke•1.8 times higher for bloodstream infections•2.0 times higher for kidney diseases•2.3 times higher for diabetes•7.7 times higher for homicide•10.9 times higher for HIV/AIDS

• The cost of the Black vs. White disparity in admission rate and severity disparities was about $800 million in Maryland for 2011.

• Black men’s prostate cancer mortality rate was 2.0 times higher compared to White men, while the Black prostate cancer incidence was 1.4 times higher.

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Social Determinants of Health Disparities and Environmental Justice

1.291.09

2.91

3.50

4.40

0.70

1.19

0.00

1.00

2.00

3.00

4.00

5.00

HeartDisease

Death Rate

CancerDeath Rate

DiabetesED visit rate

HTN EDvisit rate

Asthma EDvisit rate

% adults atgood

weight**

% adultscurrentsmoker

Bla

ck t

o W

hit

e r

ate

ra

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Black to White Rate Ratio for Selected Chronic Disease Metrics,Maryland SHIP data

Source: Maryland Asthma Surveillance Report, Asthma in Maryland, 2011. and BRFSS 2006-2010

** higher is better,

Blacks are worse off

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Asthma Disparity in Maryland Black vs. White Disparity Rate for Adults with Asthma, Maryland 2009

1.1

5.0

3.12.3

0

2

4

6

8

10

Prevalence ED Visits Hospitalization Mortality

Bla

ck v

s. W

hite

Rat

io

Black-White Disparity Ratio for Adults with Asthma, Maryland 2009

Maryland BRFSS, 2009; Maryland HSCRC, 2009; Maryland VSA, 2005-2009 Rates are age-adjusted to the 2000 U.S. standard population.  Source: Maryland Asthma Surveillance Report, Asthma in Maryland 2011

Access to healthcarehas becomethe major issue forhigher mortality rateamong Blacks in Maryland.

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Progress in DisparityElimination in Maryland

Between 2000 and 2009 the gaps between the Black and White age-adjusted death rates (Black rate minus White rate) were reduced as follows:

– For All-cause Mortality, the gap was reduced by 39%

– For Cancer Mortality, the gap was reduced by 63%

– For Heart Disease Mortality, the gap was reduced by 6%

– For Stroke Mortality, the gap was reduced by 43%

– For Diabetes Mortality, the gap was reduced by 46%

– For HIV/AIDS Mortality, the gap was reduced by 46%

Source: CDC Wonder Mortality Data 2000-2009

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Maryland Plan to Eliminate Minority Health Disparities Plan of Action 2010-2014

Objective 1: AWARENESS – Increase awareness of the significance of health disparities, their impact on the state and local communities, and the actions necessary to improve health outcomes for Maryland’s racial and ethnic minority populations.

Objective 2: LEADERSHIP – Strengthen and broaden leadership for addressing health disparities at all levels.

Objective 3: HEALTH AND HEALTH SYSTEM EXPERIENCE – Improve health and health care outcomes for racial and ethnic minorities and underserved populations and communities.

Objective 4: CULTURAL AND LINGUISTIC COMPETENCY – Improve cultural and linguistic competency.

Objective 5: RESEARCH AND EVALUATION – Improve coordination and use of research and evaluation outcomes.

The Action Plan’s main objectives include:

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The Maryland Health Improvement and Disparities Reduction Act

The Maryland Health Improvement and Disparities Reduction Act (SB 234) was signed on April 10, 2012.

•The new law has six main provisions

1. Establish Health Enterprise Zones (HEZ) in small geographic areas having very poor health statistics, health disparities and high poverty. The HEZ is eligible for loan repayment assistance, tax credits, capital equipment credits, electronic medical records assistance and participation in the Patient Centered Medical Home program, and funding for four years.

2. Establish and incorporate a standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports generated by the Maryland Health Care Commission.

3. Require each non-profit hospital in the State to include in their Annual Community Benefits Reports, a description of the hospital's efforts to track and reduce health disparities.

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The Maryland Health Improvement and Disparities Reduction Act (Continued)

4. Require institutions that offer programs necessary for the licensing of health care professionals in the State to report on their actions taken to reduce health disparities.

5. Two State commissions that work with hospital and health insurer data, shall recommend standards for evaluating the impact of the Maryland Patient Centered Medical Homes on eliminating health disparities.

6. Form a Workgroup to develop standards and criteria for cultural competency in medical and behavioral health treatment settings

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Health Enterprise Zones (HEZs)

The purposes of establishing HEZs is to target State resources to:

• Reduce health disparities among racial and ethnic groups and geographic areas;

• Improve health care access and health outcomes in underserved communities; and

• Reduce healthcare costs and hospital admissions/readmissions.

• The criteria of becoming an HEZ are: • Each HEZ is a contiguous geographic area;

• Must have documented evidence of health disparities, economic disadvantage and poor health outcomes; and

• Small enough to allow incentives to have a significant impact but large enough to track data (population of at least 5,000).

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The Reduction Act’s Implications for Environmental Justice and Health Equity

• HEZ alleviates environmental health disparities by

concentrating and targeting resources at contiguous

geographic areas (Zipcodes) where disadvantaged

populations experiencing poor health outcomes;

• The Reduction Act allows hospitals and other health care

settings to track health disparities data (e.g., asthma, lead

poisoning, cancer, birth defects, etc.,) broken down by race

and ethnicity;

• Workforce and student cultural competency training among

various health care settings and higher education

institutions.

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Online Resources

• Maryland Minority Health and Health Disparities

http://dhmh.maryland.gov/mhhd/SitePages/Home.aspx

• Health Disparities Workgroup Final Report and Recommendations. E, Albert Reece, MD., PhD., MBA. Maryland Health Quality and Cost Council.

 http://www.governor.maryland.gov/ltgovernor/documents/disparitiesreport120117.pdf

• Maryland Health Improvement and Disparities Reduction Act of 2012

http://mlis.state.md.us/2012rs/bills/sb/sb0234t.pdf

• Maryland State Health Improvement Process (SHIP)

http://dhmh.maryland.gov/ship/SitePages/Home.aspx

• Maryland Health Disparities Plan of Action 2010

http://dhmh.maryland.gov/mhhd/Documents/Maryland_Health_Disparities_Plan_of_Action_6.10.10.pdf

• Maryland Health Disparities Data Chartbook 2012

http://dhmh.maryland.gov/mhhd/Documents/2012%20Maryland%20Health%20Disparities%20Data%20Chartbook.pdf

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Contact Information

Office of Minority Health and Health Disparities

Maryland Department of Health and Mental Hygiene201 West Preston Street, Room 500

Baltimore, Maryland 21201

Website: www.dhmh.maryland.gov/mhhdFacebook: www.facebook.com/MarylandMHHD

Phone: 410-767-7117Fax: 410-333-5100

Email: dhmh.healthdisparities@maryland.gov