 1pm EST  Webinar will begin shortly.

 Dr. Terry Cline, PhD; Commissioner, Oklahoma State Department of Health

 Dr. Brian Smedley, PhD, Vice President and Director, Health Policy Institute of the Joint Center for Political and Economic Studies  Anna Whiting Sorrell, MPA, Director, Montana Department of Public Health and Human Services  Jane Smilie, MPH, Administrator, Montana Department of Public Health and Human Services, Public Health and Safety Division  John Auerbach, MBA, Commissioner, Massachusetts Department of Public Health

Challenges and Opportunities in Advancing Health Equity: Making the Economic Case Brian D. Smedley, Ph.D. Joint Center for Political and Economic Studies

The Economic Burden of Health Inequalities in the United States ( Direct medical costs of health inequalities Direct medical costs of health inequalities Indirect costs of health inequalities Indirect costs of health inequalities Costs of premature death Costs of premature death

The Economic Burden of Health Inequalities in the United States Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asian Americans, and Hispanics were excess costs due to health inequalities. Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asian Americans, and Hispanics were excess costs due to health inequalities. Eliminating health inequalities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years Eliminating health inequalities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years Between 2003 and 2006 the combined costs of health inequalities and premature death were $1.24 trillion. Between 2003 and 2006 the combined costs of health inequalities and premature death were $1.24 trillion.

Geography and Health – the U.S. Context The “Geography of Opportunity” – the spaces and places where people live, work, study, pray, and play powerfully shape health and life opportunities. The “Geography of Opportunity” – the spaces and places where people live, work, study, pray, and play powerfully shape health and life opportunities. Spaces occupied by people of color tend to host a disproportionate cluster of health risks, and have a relative lack of health-enhancing resources. Spaces occupied by people of color tend to host a disproportionate cluster of health risks, and have a relative lack of health-enhancing resources.

The Role of Segregation

Racial Residential Segregation – Apartheid- era South Africa (1991) and the US (2010) Source: Massey 2004; Frey 2011

Negative Effects of Segregation on Health and Human Development Racial segregation concentrates poverty and excludes and isolates communities of color from the mainstream resources needed for success. African Americans are more likely to reside in poorer neighborhoods regardless of income level. Racial segregation concentrates poverty and excludes and isolates communities of color from the mainstream resources needed for success. African Americans are more likely to reside in poorer neighborhoods regardless of income level. Segregation also restricts socio-economic opportunity by channeling non-whites into neighborhoods with poorer public schools, fewer employment opportunities, and smaller returns on real estate. Segregation also restricts socio-economic opportunity by channeling non-whites into neighborhoods with poorer public schools, fewer employment opportunities, and smaller returns on real estate.

Negative Effects of Segregation on Health and Human Development (cont’d) African Americans are five times less likely than whites to live in census tracts with supermarkets, and are more likely to live in communities with a high percentage of fast-food outlets, liquor stores and convenience stores African Americans are five times less likely than whites to live in census tracts with supermarkets, and are more likely to live in communities with a high percentage of fast-food outlets, liquor stores and convenience stores Black and Latino neighborhoods also have fewer parks and green spaces than white neighborhoods, and fewer safe places to walk, jog, bike or play, including fewer gyms, recreational centers and swimming pools Black and Latino neighborhoods also have fewer parks and green spaces than white neighborhoods, and fewer safe places to walk, jog, bike or play, including fewer gyms, recreational centers and swimming pools

Negative Effects of Segregation on Health and Human Development (cont’d) Low-income communities and communities of color are more likely to be exposed to environmental hazards. For example, 56% of residents in neighborhoods with commercial hazardous waste facilities are people of color even though they comprise less than 30% of the U.S. population Low-income communities and communities of color are more likely to be exposed to environmental hazards. For example, 56% of residents in neighborhoods with commercial hazardous waste facilities are people of color even though they comprise less than 30% of the U.S. population The “Poverty Tax:” Residents of poor communities pay more for the exact same consumer products than those in higher income neighborhoods­– more for auto loans, furniture, appliances, bank fees, and even groceries The “Poverty Tax:” Residents of poor communities pay more for the exact same consumer products than those in higher income neighborhoods­– more for auto loans, furniture, appliances, bank fees, and even groceries

Metro Cleveland: Poverty Concentration of Neighborhoods of All Children Source: Diversitydata.org, 2011

Metro Cleveland: Poverty Concentration of Neighborhoods of Poor Children Source: Diversitydata.org

Metro Detroit: Poverty Concentration of Neighborhoods of All Children Source: Diversitydata.org, 2011

Metro Detroit: Poverty Concentration of Neighborhoods of Poor Children Source: Diversitydata.org

How can we eliminate health status inequality? Expand place-based opportunity: Reduce residential segregation by expanding housing mobility programs (e.g., portable rent vouchers and tenant-based assistance) Reduce residential segregation by expanding housing mobility programs (e.g., portable rent vouchers and tenant-based assistance) Vigorously enforce anti-discrimination laws in home lending, rental market, and real estate transactions Vigorously enforce anti-discrimination laws in home lending, rental market, and real estate transactions Encourage greater commercial, business and housing development in distressed communities Encourage greater commercial, business and housing development in distressed communities Expand public transportation to connect people in job- poor areas to communities with high job growth Expand public transportation to connect people in job- poor areas to communities with high job growth

How can we eliminate health status inequality? Improve public schools and educational opportunities: Expand high-quality preschool programs Expand high-quality preschool programs Create incentives to attract experienced, credentialed teachers to work in poor schools Create incentives to attract experienced, credentialed teachers to work in poor schools Take steps to equalize school funding Take steps to equalize school funding Expand and improve curriculum, including better college prep coursework Expand and improve curriculum, including better college prep coursework Reduce financial barriers to higher education Reduce financial barriers to higher education

How can we eliminate health status inequality? Create healthier communities: Address environmental degradation through more aggressive regulation and enforcement of laws and Consolidated Environmental Review Address environmental degradation through more aggressive regulation and enforcement of laws and Consolidated Environmental Review Structure land use and zoning policy to reduce the concentration of health risks Structure land use and zoning policy to reduce the concentration of health risks Institute Health Impact Assessments to determine the public health consequences of any new housing, transportation, labor, education policies Institute Health Impact Assessments to determine the public health consequences of any new housing, transportation, labor, education policies

Expanding Housing Mobility Options: Moving To Opportunity (MTO) U.S. Department of Housing and Urban Development (HUD) launched MTO demonstration in 1994 in five cities: Baltimore, Boston, Chicago, Los Angeles, and New York. U.S. Department of Housing and Urban Development (HUD) launched MTO demonstration in 1994 in five cities: Baltimore, Boston, Chicago, Los Angeles, and New York. MTO targeted families living in some of the nation’s poorest, highest- crime communities and used housing subsidies to offer them a chance to move to lower-poverty neighborhoods. MTO targeted families living in some of the nation’s poorest, highest- crime communities and used housing subsidies to offer them a chance to move to lower-poverty neighborhoods. Away from concentrated poverty, families fare better in terms of physical and mental health, risky sexual behavior and delinquency. Adolescent girls benefited from moving out of high poverty more than boys. Away from concentrated poverty, families fare better in terms of physical and mental health, risky sexual behavior and delinquency. Adolescent girls benefited from moving out of high poverty more than boys.

“[I]nequities in health [and] avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces.” World Health Organization Commission on the Social Determinants of Health (2008)

Health Inequities in Montana Anna Whiting Sorrell, MPA, Director Montana Department of Public Health & Human Services (DPHHS) Jane Smilie, MPH, Administrator Public Health and Safety Division, DPHHS

Social Determinants of Health Inequities in Montana Some sources of inequity in Montana – Low income/poverty – Low educational attainment – Medically underserved rural areas American Indians are more often affected in our state

Social Determinants of Health Inequities in Montana

Inequities in Life Expectancy in Montana

Leading Causes of Death in Montana

Modifiable Risk Factors for Chronic Diseases

Cancer Incidence in Montana

Cancer Screening Participation in Montana

Critical Interventions for Chronic Disease Tobacco cessation Risk factor management – Weight – Diabetes control – Blood pressure – Cholesterol Cancer screening

Outreach to American Indians in Montana for Chronic Disease Funding – All tribes and UICs for tobacco prevention Community-based educational campaigns – Tobacco – Heart attack and stroke awareness Technical assistance – Blood pressure and cholesterol management – Implement Diabetes Prevention Program

Outreach to American Indians in Montana for Chronic Disease Cancer Screening – Since 1996 – American Indian outreach initiated 2000 MAIWHC – Almost 1,200 American Indian women screened for Breast and Cervical Cancer 19% of all screenings – Colorectal screening added in 2010

Inequities in Pregnancy Risk Factors in Montana

Critical Interventions to Improve Maternal and Child Health Reduce teen pregnancy – Access to highly effective contraceptives – Promote delay in sexual activity Home visiting programs for high-risk families – Expectant parents – Caregivers of infants and preschoolers

Outreach to American Indians to Reduce Teen Pregnancy Working with two tribes to implement teen pregnancy and STI prevention curricula in middle and high schools – New, pilot projects – Draw the Line/Respect the Line – Reducing the Risk

Outreach to American Indians through Home Visiting Funding to every tribe for community participation for development of community-specific home visiting programs – Needs assessment – Will promote smoking cessation and early entry into prenatal care

Inequities in Communicable Diseases in Montana

Critical Interventions to Reduce Sexually Transmitted Diseases Screening and early detection Case investigation Contact tracing Treatment including partner-delivered patient therapy

Outreach to American Indians in Montana for Communicable Disease Work closely with Tribal Health Departments and I.H.S. Units – Screening – Contact tracing – Treatment Goals – Prevent spread – Prevent complications that have serious health effects and lifelong consequences

Outreach to American Indians to Reduce Vaccine-Preventable Diseases in Montana Childhood Immunization – VFC provides vaccines at no cost for American Indian children Tribal clinics have higher up-to-date rates – Tribal 68% of children fully immunized – Statewide 52%

Summary and Conclusions American Indian residents experience more barriers to improved health DPHHS effective outreach activities – Community-based – Proven-effective interventions Leadership Integrated into the work of all programs

Massachusetts Department of Public Health The Elimination of Health Disparities – A Public Health Priority John Auerbach, MBA Commissioner of Health

Why Should this be a Priority?

46 HIV/AIDS Death Rate by Race/Ethnicity Western Region and Massachusetts: NA Age-adjusted to the 2000 US standard population. Source: MDPH, Bureau of Health Information, Statistics, Research, & Evaluation Bureau, Division of Research & Epidemiology State Overall: 2.1

47 Asthma Emergency Department Visit Rates Children Ages 0-14 Western Region and Massachusetts: 2008 Age-adjusted to the 2000 US standard population. Source: Division of Health Care Finance and Policy. Calendar Year Emergency Department Visits * Statistically different from State (p ≤.05) State Overall: 958.2

48 Prevalence of Diabetes in Massachusetts Adults Varies Significantly by Race/Ethnicity † Insufficient data*significantly higher than White, NH SOURCE: MA Behavioral Risk Factor Surveillance System (BRFSS), 2010 † * *

Additional Areas of Health Disparity Often intensifying racial and ethnic disparities

50 Educational Level 15+ Days of Poor Mental Health in Past Mo. by Level of Education Data Source: MA Behavioral Risk Factor Surveillance System

51 Disability Status Females Who Report Sexual Violence by Age & Disability Status, Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS) –

52 What Causes These Disparities?

53 Poverty is a Major Factor Variation in Diabetes Prevalence Among Adults by Household Income Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS)

54 Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state Source: MA Behavioral Risk Factor Surveillance System (BRFSS), 2010 Education is a Major Factor Diabetes by Education, Massachusetts Adults, 2010

55 The community-level obstacles to healthier behaviors In poorer neighborhoods: –Healthy food less available & affordable –More fast food restaurants and stores that sell less healthy foods –Fewer parks, recreation centers and safe places to exercise –More cigarette advertising

56 Hispanic workers are at high risk of fatal occupational injury in Massachusetts Deaths per 100,000 workers Source: MA FACE and Census of Fatal Occupational Injuries,

57 Less access to health care

58 Discrimination as a Factor Racial/Ethnic Discrimination and Health: Findings From Community Studies David R. WilliamsDavid R. Williams, PhD, MPH, Harold W. Neighbors, PhD, and James S. Jackson, PhDHarold W. Neighbors James S. Jackson “Perceptions of discrimination appear to induce physiological and psychological arousal, and, as is the case with other psychosocial stressors, systematic exposure to experiences of discrimination may have long-term consequences for health. These experiences are part of the social and psychological context in which disease risk emerges and within which effective interventions to improve health must be embedded.”

What Can be Done in Public Health to Address the Issue?

60 Hire Diverse Leadership After years of little diversity in leadership…

61 Focus Attention at the Highest Levels Creation of DPH Health Equity Office Management of disparities and other grants Involvement in senior policy inside and outside of DPH Use of the position as a bully pulpit

62 Provide Information on Disparities Regulatory mandate that hospitals collect and report accurate, consistent patient race and ethnicity data

63 Issue Special Reports

64 Promote Higher Quality Services… “Making CLAS Happen” contribute to the elimination of racial and ethnic health disparities make services more responsible to the individual needs of clients are inclusive of all cultures, while specifically designed to address the needs of racial, ethnic, and linguistic minority groups. CLAS (Culturally and Linguistically Appropriate Services) Standards (US DHHS, 2001)

65 Provide Specialized Funding, if possible Release of $1M dollars to support innovative efforts throughout the state Adapt existing DPH programs to reflect focus on racial and ethnic disparities (new RFP criteria)

66 Work with Local Communities Supporting local screenings of Unnatural Causes* to build awareness about health disparities. Working with communities to develop goals to eliminate disparities in health. *Unnatural Causes Produced by California Newsreel

67 Develop Targeted Campaigns

68 Focus on access to health insurance % of MA Adults under 65 without Health Insurance, by Race/Ethnicity, All percentages are age-adjusted to standard population (U.S. 2000) Chart shows two-year moving averages Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS)

69 Make the economic argument Poor health costs more – higher premiums and more out of pocket costs Poor adult health leads to more absenteeism and less productivity Poor children’s health leads to more school absenteeism and drop- outs TFAH Report; RWJ grant

 For more information, please contact: ◦ Meenoo Mishra, MPH, Senior Analyst of Health Equity at