This document summarizes a presentation on lessons Canada can learn from health equity initiatives in the United States. It outlines statistics showing disparities in health insurance coverage and outcomes in the US. It then discusses current US health care reform efforts and provisions aimed at reducing disparities. Finally, it examines state and local programs in Massachusetts, Boston, California, and New Jersey focused on improving data collection, workforce diversity, interpretation services, and cultural competency training to promote equity. The presenter argues Canada could benefit from similar efforts like establishing an Office of Health Equity and improving data and collaboration across sectors.

1. Health Equity Lessons from…the
United States? Really?
Matt Kanter
December 16, 2009
© The Wellesley Institute
www.wellesleyinstitute.com

2. Outline of Presentation
• Health Equity Statistics in the U.S.
• Discuss Current U.S. Health Care Reform
• State and Local Equity Initiatives
• Massachusetts
– The City of Boston
• California
• New Jersey
• Possible Lessons for Canada
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3. Health Equity in the U.S.
• Canadians’ perceptions of the American
health care system
• Medical expenditures are the leading cause
of personal bankruptcies in the U.S.
• What could the U.S. possibly teach Canadians
about Health Equity?
• First, the statistics…
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4. Health Equity in the U.S.: The Uninsured
• 17.4% of non-elderly Americans are
uninsured (45.7 million people)
• 32% of those considered “low-income” lack
health insurance
• 10.3% of children are uninsured
• 20.6% of African-Americans and 32.2% of
Hispanic Americans do not have insurance
• 18.8% of non-elderly workers are uninsured
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5. Health Equity in the U.S.: Health Spending
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6. Health Equity in the U.S.: Health Spending
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7. Health Equity in the U.S.: Health
Outcomes
• Life Expectancy:
• U.S.: 78.1 years
• Canada: 80.7 years
• OECD Average: 79.0 years
• The U.S. also has vast disparities in health care
quality and outcomes across race, ethnicity, SES,
gender, place of residence (urban vs. rural) and
language (Institute of Medicine)
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8. Current U.S. Health Care Reform
Explained
• (1) The Political Process: Where are We?
• (2) The Basics of Reform (H.R. 3962)
• (3) Forgotten (Ignored?) Health Equity
Elements of the Proposed Legislation
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9. Health Care Reform: The Process
• House: Blended Bill passed November 7,
2009 (220 – 215)
• Senate: Blended bill introduced on November
18, 2009; No vote yet
• What’s Next? If it passes the senate, a joint
House/Senate Committee will re-write the
bill which must pass both houses and be
signed by the President
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10. Health Care Reform: The Basics
• Individual Mandate
– With Subsidies
• Employer Mandate
• National Health Insurance Exchange
– With a Public Option?
• Key Changes to Private Insurance
• Paying for the Legislation/Cost Containment
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11. Health Care Reform: Forgotten (Ignored?)
Health Equity Initiatives
Health Disparities Definition (in H.R. 3962):
“‘Health Disparities’ includes health and health
care disparities and means population
specific differences in the presence of
disease, health outcomes or access to care”
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12. Health Care Reform: Forgotten (Ignored?)
Health Equity Initiatives
• ss. 1221 – 1223: Concerned with reducing language
barriers for limited-English-proficiency populations
• Sec 1442: The Secretary shall ensure that reducing
health disparities is an explicit goal in her national
priorities for quality improvement in health care
• Sec 2251: The Secretary shall establish a cultural
and linguistic competency training program for
health professionals
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13. Health Care Reform: Forgotten (Ignored?)
Health Equity Initiatives
• Sec 2301: The CDC shall establish a program for the delivery
of community based-preventive/wellness services
– At least 50% of the funds must be spent on planning/implementing wellness
services whose primary purpose is to achieve a measurable reduction in one
or more health disparities
• Sec 2402: The Department of HHS shall establish the
position of Assistant Secretary for Health Information
– The Assistant Secretary shall “facilitate and coordinate identification and monitoring of
health disparities…to inform program and policy efforts to reduce health disparities”
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14. State and Local Equity Initiatives:
Massachusetts
Chapter 58 of the Acts of 2006
• Based on the premise of shared responsibility
– Included an individual mandate with subsidies for low-income
individuals, an employer mandate and a state-wide insurance
exchange (called “The Connector”)
• 2 years after implementation, 439,000 people had
signed up for health insurance
– The uninsurance rate dropped from 11% in 2005 to 2.6%
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15. Massachusetts Continued
• The MA legislation also contains several provisions
which deal explicitly with reducing health
disparities
• Legislation creates a Health Disparities Council
• It also requires a study on the possibility/cost-
effectiveness of using CHWs to reduce racial/ethnic
health disparities
• Subsequently, MA developed an Office of Health
Equity within the State Department of Health and
Human Services
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16. State and Local Equity Initiatives:
The City of Boston
• First U.S. city to establish a comprehensive plan to eliminate
racial and ethnic health disparities (2005)
• Disparities Project made 12 recommendations, including:
– (1) Requiring health care organizations to gather uniform patient data on race,
ethnicity, language and SES
– (2) Developing skills to enable community members to become better
informed and equipped patients
– (3) Providing cultural competence education and training to health care
professionals
– (4) Increasing resources to improve workforce diversity
– (5) Increasing public awareness about health disparities
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17. Boston Continued
• One year into the Project, significant results,
including:
– Significant progress toward building a uniform data collection
system
– More than 460 health care professionals completed cultural
competency training
– Approximately 3,000 people were directly involved in targeted
community-wide education, training and advocacy;
– 3,000 more received direct patient education and support
– The Boston Neighborhood Network (BNN) created an 8-
segment TV series about the Disparities Project
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18. State and Local Equity Initiatives:
California
Health Care Language Assistance Act (SB 853) – Key Elements
• Health plans must conduct a needs assessment to calculate threshold
languages and collect race, ethnicity and language data
• Health plans must provide quality, accessible and timely access to
interpreters at all points of contact in the health care system and at no
cost to the enrollee
• Health plans must translate vital documents into threshold languages
• Health plans must ensure that interpreters are trained, competent and
that translated materials are of high quality
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19. State and Local Equity Initiatives:
New Jersey
• In 2005, NJ became the first state to develop mandatory
cultural competency training for physicians
• SB 144 requires medical professionals to receive cultural
competency training to graduate from a NJ med school or to
get (or renew) a license to practice medicine
• Improving cultural competence is widely recognized as
integral to the reduction of health disparities
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20. Potential Lessons for Canada
• (1) Create an Office of Health Equity
• (2) Need Uniform Data Collection and
Analysis
• (3) Recruit a Diverse Workforce
• (4) Need Collaboration Among Stakeholders
• (5) The Importance of Quality, Trained Health
Care Interpretation
• (6) Increased Cultural Competency Training
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21. Questions and Discussion
Any questions/comments?
Paper available here:
http://www.wellesleyinstitute.com/files/Hea
lth%20Equity%20Lessons%20from%20the%2
0US%20-%20Formatted%20v.3_1.pdf
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