A model for policy advancement in cultural literacy and health inequalities

As the US emerges from a long recession, managing rising healthcare costs remains an ongoing concern. The Affordable Health Act will eventually ensure the availability of health insurance coverage for over 30 million more Americans. This landmark legislation will increase access to a previously uninsured or underinsured group of Americans.

Health and health inequalities are broadly defined as poorer baseline health conditions and relatively poorer clinical outcomes associated with specific diseases in specific populations. Affected groups can be differentiated by race, ethnicity, culture, gender, religion and age. The cost of treating diseases resulting from health and healthcare disparities is one of the recognized areas of unnecessary and arguably avoidable healthcare costs. In particular, in certain cases, both prevention and more cost-effective treatment of chronic disease conditions can significantly reduce healthcare costs. A chronic disease is defined as a long-standing or recurring medical condition.

Some common examples are diabetes, high blood pressure, asthma and cardiovascular disease. Unfortunately, our current healthcare system may be better equipped to handle the emergence of intermittent and episodic illness than the demands of chronic illness. In a study by Weidman et al. Hispanics and non-Hispanic whites will cost the healthcare system $23.9 billion. Medicare alone will spend an additional $15.6 billion, while private insurers will incur an additional $5.1 billion in costs due to increased chronic disease rates among these groups of Americans. Over the 10-year period from 2009 to 2018, the authors estimated the total cost of these differences to be approximately $337 billion, including $220 billion for Medicare.

In the same study, the authors estimated the total healthcare costs due to racial and ethnic health disparities in treating chronic diseases (diabetes, hypertension, stroke, kidney disease, poor general health) among African Americans and Hispanics residing in the Commonwealth of Pennsylvania to be $700 million. The Municipal Institute. A study entitled The Economic Burden of Health Inequalities in the United States by LaVeist et al. measured the economic burden of health inequalities in the United States using three measures: (1) direct medical costs of health inequalities (2) indirect costs of health inequalities (3) costs of premature death Their results showed:

  • The combined cost of health inequality and premature death in the United States among African Americans, Hispanics, and Asian Americans was $1.24 trillion
  • Eliminating health inequalities for minorities would have reduced direct medical expenditures by $229.4 billion in 2003-2006
  • Between 2003 and 2006, 30.6% of direct medical expenses for African Americans, Asians, and Hispanics were excess costs due to health inequalities.

Cultural Competence (CC) refers to the ability to interact effectively with people of different cultures. CC comprises four components: (a) awareness of one’s cultural worldview, (b) attitude towards cultural differences, (c) knowledge of different cultural practices and worldviews and (d) intercultural competences. The development of cultural competence leads to the ability to understand, communicate with and interact effectively with people of different cultures. CC is increasingly recognized as an important, overlooked and underappreciated factor in delivering healthcare to an increasingly diverse America. The US Census estimates that by 2050 over 50% of Americans will be non-white. Over 50% of children will be non-white by 2025. It seems intuitive that the interface between patient, healthcare system and healthcare provider is a critical point in healthcare. To that end, the Office of Minority Health in the Department of Health and Human Services has issued mandates and recommendations to inform, guide, and facilitate the creation of culturally and linguistically appropriate services. (CLASS Culturally and Linguistically Appropriate Services). Implementation of these guidelines within systems and agencies and between individuals can improve CC and ultimately improve clinical outcomes. The Center for Health Improvement and Economic Development was one of several parties advocating statewide guidelines regarding cultural competency (CME) requirements for initial and re-licensing of physicians in the Commonwealth of Pennsylvania. To achieve this goal, we set out to educate and inform diverse stakeholders about the intrinsic value of CC as a critical determinant of improving healthcare outcomes and as a direct result of a utilitarian social justice argument in the United States. The Center also recognized the importance of a compelling business model in the current economic climate. Partnerships with the Gateway Medical Society, the Pennsylvania State Legislative Black Caucus (PSLBC) led by State Representative Ronald G. Waters, and the Center for Health Improvement and Economic Development – a townhall format meeting was organized and scheduled in Pittsburgh. Local lawmakers including state representatives Jake Wheatley, Tom Preston and Daniel Frankel were in attendance.

The town hall program: Working to Eliminate Health Inequalities in the Commonwealth of Pennsylvania took place in Pittsburgh. Attendees and participants included government policy makers, lawmakers, healthcare providers, healthcare administrators, social activists, business leaders and members of the general public. Vigorous debates raged throughout the day, and exchanges between listeners, lawmakers, policymakers and thought leaders underscored the recognized importance of the critical issue of health inequalities and cultural literacy. It is important to understand the background of the day’s events. The meeting came two days after the first steps of the Affordable Care Act were launched with crucial new consumer protections in living wills, including no pre-existing medical conditions for children, the ban on revocation and the creation of a pathway to allow adult children to remain on the insurance of their parents up to the age of 26. The day’s enthusiasm culminated with State Representative Ronald G Waters’ pledge to support a resolution on CC to be presented to the National Black Caucus of State Legislators — ultimately a path to introducing legislation to all states and eventually to the Congressional Black Caucus . The meeting emphasized the need and benefits of identifying stakeholders, recognizing common agendas and seeking consensus en route to generating support for public policies. Addressing CC in healthcare through continuing education requirements for healthcare providers is a small step. Certainly this requirement should be considered for other healthcare professionals, administrators and support workers. Greater awareness of America’s emerging diversity and understanding how to manage that diversity will greatly improve healthcare delivery. The Pennsylvania State Legislative Black Caucus, the Center for Health Improvement and Economic Development, and the Gateway Medical Society call on other groups to join our collaborative model to reduce health inequalities and improve health care in the Commonwealth of Pennsylvania and beyond.

The Pennsylvania Legislative Black Caucus The PLBC was organized by House Majority Leader K. Leroy Irvis during the 1973-74 legislature. K. Leroy Irvis saw the need for the caucus because he believed that legislators representing minority districts needed to speak with one voice on the issues and concerns of their constituents. State Representative Ronald G. Waters was first elected to the House of Representatives in a special election in May 1999. He chairs the Subcommittee on Health and Human Services for Health and serves on the Child and Youth, Health and Human Services, Justice and Alcohol Control and Professional Licensing Committees. He is also a member of the Philadelphia and Southeast Pennsylvania delegations. Waters is also Chair of the Pennsylvania Legislative Black Caucus and Chair of Region 2 (which includes Pennsylvania and New York) of the National Black Caucus of State Legislators. About the authors: Lee Kirksey MD is co-founder of the Center for Health Improvement and Economic Development, a public policy think tank. The organization focuses on the impact of social determinants on community health through the use of public-private partnerships. His current research efforts include cultural competence and its impact on health disparities in surgery. He is the author of The Wellness Revolution: Eliminating Disparities and Promoting Prevention…For All. dr Kirksey is an assistant professor of surgery at the University of Pennsylvania School of Medicine. Michele Jones, MSW, MHA, is the Partnership Development and Community Relations Manager at Fox Cancer Center in Philadelphia. Ms. Jones has over 15 years of management experience in health inequality, health education, outreach and development, and is responsible for prevention practices and partnership development. Over the years she has worked in similar roles at companies in San Diego, New York and Pennsylvania. Her work has earned her recognition as an innovator in health access, prevention and education, and has received City Citations and awards for both community outreach and health education. Jones is the founder of Jones Health Care Management Solutions and is currently a sophomore in bioethics at the University of Pennsylvania School of Medicine.

The Gateway Medical Society The Gateway Medical Society is part of the National Medical Association. The goals of the National Medical Association are to advance the science and art of medicine and to improve public health. Established in 1895, the NMA limits membership to physicians licensed to practice medicine in any state or territory of the United States and the District of Columbia. Membership election can be achieved through constituent associations, through affiliation with societies composed of organized women physicians, Haitian physicians and other minority physicians. The Gateway Medical Society is therefore a subsidiary of its constituent association, the Keystone State Medical Society of Pennsylvania.

LaVeist TA, Gaskin DJ, Richard P, The Economic Burden of Health In Equality in the US. Joint Center for Political and Economic Studies. Accessed October 10, 2010

National Standards for Culturally and Linguistically Appropriate Health Services, Final Report, OMH, 2001