CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES

Workshop Summary

Jennifer A. Cohen, Rapporteur

Roundtable on Health Disparities

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Jennifer A. Cohen, Rapporteur Roundtable on Health Disparities Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by multiple contracts and grants between the National Academy of Sciences and the Agency for Healthcare Research and Quality and the Office of Minority Health, U.S. Department of Health and Human Service (Contract HHSP23320042509XI, TO#11); California Endowment (Contract 20052634); California HealthCare Foundation (Contract 06-1213); Commonwealth Fund (Contract 20060048); Connecticut Health Foun- dation (unnumbered grant); Ford Foundation (Contract 1050-0152,FF5H003); Healthcare Georgia Foundation (unnumbered grant); The Henry J. Kaiser Family Foundation (Contract 01-1149-810); Kaiser Permanente (Contract 20072164); Merck (unnumbered grant); Missouri Foundation for Health (Contract 06-0022-HPC); Robert Wood Johnson Foundation (Con- tract 56387); and W. K. Kellogg Foundation (Contract P0123822). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-11690-9 International Standard Book Number-10: 0-309-11690-2 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2008. Challenges and successes in reducing health disparities: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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ROUNDTABLE ON HEALTH DISPARITIES* Nicole Lurie (Chair), Senior Natural Scientist, RAND Corporation, Arlington, VA Victoria Holloway Barbosa, President, Dermal Insights, Inc., Chicago, IL Anne C. Beal, Senior Program Officer, Quality of Care for Underserved Populations, The Commonwealth Fund, New York Cheryl A. Boyce, Executive Director, Ohio Commission on Minority Health, Vern Riffe Center for Government and the Performing Arts, Columbus, OH America Bracho, CEO, Latino Health Access, Anaheim, CA Francis D. Chesley, Director, Office of Extramural Research, Education and Priority Populations, Agency for Healthcare Research and Quality, Rockville, MD Todd Cox, Program Officer, Racial Justice and Minority Right, Ford Foundation, New York William F. Crimi, Vice President, Program and Evaluation, Connecticut Health Foundation, New Britain, CT Alicia Dixon, Program Officer, The California Endowment, Los Angeles José J. Escarce, Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles Garth N. Graham, Deputy Assistant Secretary, Minority Health Department of Health and Human Services, Office of Minority Health, Rockville, MD Tom Granatir, Director, Policy and Communications, Innovation Center Humana, Inc., Chicago, IL Cara V. James, Senior Policy Analyst, Henry J. Kaiser Family Foundation, Washington, DC Jennie R. Joe, Professor, Department of Family and Community Medicine, and Director, NARTC, University of Arizona, College of Medicine, Tucson, AZ James R. Kimmey, President and CEO, Missouri Foundation for Health, St. Louis, MO Howard K. Koh, Associate Dean and Director, Division of Public Health Practice, Harvard School of Public Health, Boston, MA James Krieger, Chief, Epidemiology Planning and Evaluation Unit, Seattle, WA Anne C. Kubisch, Co-Director, Roundtable on Community Change, Aspen Institute, New York * IOM forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. 

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Jeffrey Levi, Executive Director, Trust for America’s Health, Washington, DC James C. Lewin, Chief Executive Officer, American College of Cardiology, Washington, DC Jane Isaacs Lowe, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ Richard K. Murray, Vice President, External Medical and Scientific Affairs, U.S. Human Health, Merck and Company, Inc., North Wales, PA Gary D. Nelson, President, Healthcare Georgia Foundation, Atlanta, GA Samuel Nussbaum, Executive Vice President and Chief Medical Officer, WellPoint, Inc., Indianapolis, IN Michael W. Painter, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ David P. Pryor, Medical Director, Aetna; Founder, Black Women Health.com, Thousand Oaks, CA Steve M. Pu, General Surgeon, Missouri Foundation for Health, Kennett, MO Kyu Rhee, Director, Office of Innovation and Program Coordination, National Center on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD Mark D. Smith, President and CEO, California Health Care Foundation, Oakland Mildred Thompson, Senior Director, PolicyLink, Center for Health and Place, Oakland, CA Pattie Tucker, Lead Health Scientist, Community and Health Program, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA Winston F. Wong, Medical Director, Community Benefit Director, Disparities Improvement and Quality Initiatives, Kaiser Permanente Federation, Oakland, CA Terri D. Wright, Program Director, Health Policy, W. K. Kellogg Foundation, Battle Creek, MI IOM Board on Population Health and Public Health Practice Liaisons Samuel So, Professor, Stanford School of Medicine, Stanford University, Stanford, CA William A. Vega, Professor, Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles i

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Staff Faith Mitchell, Senior Program Officer (through July 2007) Jennifer A. Cohen, Program Officer (July 2007 through the present) Rose Marie Martinez, Board Director Thelma L. Cox, Senior Program Assistant Christie Bell, Financial Officer Christine McShane, Editor Hope Hare, Administrative Assistant ii

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Sharon E. Barrett, Association of Clinicians for the Underserved Anne C. Beal, The Commonwealth Fund Howard K. Koh, Harvard School of Public Health Brian D. Smedley, Opportunity Agenda Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Dr. Melvin Worth. Appointed by the Institute of Medicine, he was respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author and the institution. ix

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Contents Preface xiii List of Acronyms xvii 1 Introduction 1 2 The Impact of Geography on Health Disparities in the United States: Different Perspectives 7 3 Clinical and Community-Development Approaches to Reducing Disparities 47 4 Successful Clinical and Community-Development Strategies 69 5 Health Disparities in a Business Environment 91 6 Moving Forward 103 APPENDIXES A Agenda of the Public Meeting Held by the Roundtable on Health Disparities 111 B Workshop Presenters’ Biosketches and Participant List 115 C Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States 131 D Community Approaches to Addressing Health Disparities 161 xi

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Preface I n early 2007, the Institute of Medicine of the National Academies con- vened the Roundtable on Health Disparities to increase the visibility of racial and ethnic health disparities as a national problem, further the development of programs and strategies to reduce disparities, foster the emergence of leadership on this issue, and track promising activities and developments in health care that could lead to dramatically reducing or eliminating disparities. The Roundtable on Health Disparities includes representatives from the health professions, state and local government, foundations, philanthropy, academia, advocacy groups, and community- based organizations. Its mission is to facilitate communication across sectors and—above all—to generate action. Through national and local activities, the Roundtable strives to advance the goal of eliminating health disparities. On July 31, 2007, the first workshop of the Roundtable on Health Dis- parities was held at Harris-Stowe State University in St. Louis, Missouri. To help stimulate new thinking about solutions and to inform its future meet- ings and discussions, the Roundtable brought together a diverse group of participants from a variety of fields to discuss racial and ethnic differences in life expectancy in the United States. Measured in terms of life expectancy, tens of millions of Americans experience levels of health that are more typical of middle- and low-income developing countries. These mortality differences are caused primarily by chronic diseases and injuries with well- established risk factors and are potentially amenable to intervention. The goals of the workshop were to increase the Roundtable’s understanding of (1) the importance of differences in life expectancy within the United States, xiii

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xi PREFACE (2) the reasons for the differences, and (3) the implications of this informa- tion for programs and policy makers. This workshop provided the Roundtable members and sponsors with an opportunity to hear from a diverse group of people from across the country and to engage in an open dialogue about relevant issues and con- cerns related to reducing health disparities. Workshop participants offered different points of view and shared unique approaches for reducing dispari- ties. While some of the workshop participants work on reducing disparities in health care, others strive to alleviate health disparities by addressing fac- tors that determine a person’s overall health, called the social or nonmedical determinants of health. This workshop provided an open forum during which representatives from these two disparate groups could share their evidence, research, experiences, and knowledge and, together with other workshop attendees, strategize actionable goals, remedies, and solutions for reducing health disparities. ACKNOWLEDGMENTS The Roundtable on Health Disparities would like to thank all of the workshop participants for their individual contributions to this workshop. The participants’ willingness to share their time and expertise helped to inform the attendees and led to frank discussions about disparities in the United States. We would like to thank Drs. Horowitz and Lawlor for collaborating on a background paper that was commissioned by the Roundtable for this workshop. Their paper, “Community Approaches to Addressing Health Disparities,” is in Appendix D. We would also like to thank Dr. Murray for providing the Roundtable with a copy of his paper “Eight Americas: Investigating Disparities Across Races, Counties, and Race-Counties in the United States” to further clarify the material in his presentation. Dr. Murray’s published paper is in Appendix C. Presenters’ biosketches and a listing of workshop participants can be found in Appendix B. We would also like to extend our appreciation to Dr. Henry Givens, President of Harris-Stowe State University, for hosting the workshop in the Bank of America Theater at Emerson Performance Center on the Harris- Stowe State University Campus. We are also indebted to Dr. James Kimmey, President and Chief Executive Officer of the Missouri Foundation for Health, for sponsoring this workshop and for Dr. Kimmey’s tireless efforts to ensure that the workshop was a success. Special thanks are also extended to Damon Green from the Missouri Foundation for Health for all of his hard work and exceptional organizational skills. The Roundtable on Health Disparities would also like to thank IOM staff for their ongoing efforts to support the work of the Roundtable.

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xv PREFACE S ­ incere­ gratitude­ is­ extended­ to­ Dr.­ Rose­ Marie­ Martinez,­ the­ Director­ of­ the­ Board­ on­ Population­ Health­ and­ Public­ Health­ Practice;­ Dr.­ Faith­ Mitchell,­for­coordinating­and­overseeing­the­formation­of­the­Roundtable­ and­ for­ planning­ and­ organizing­ this­ workshop;­ Jennifer­ Cohen,­ for­ her­ dedication­ to­ writing­ this­ workshop­ summary­ and­ for­ her­ oversight­ and­ management­of­the­Roundtable­after­Faith’s­departure;­and­Thelma­Cox,­ for­skillfully­overseeing­all­of­the­administrative­responsibilities.­We­would­ also­ like­ to­ acknowledge­ the­ work­ of­ IOM­ staff­ members­ Christie­ Bell,­ Lara­Andersen,­Tia­Carter,­and­Hope­Hare­for­their­ongoing­assistance­and­ support.­ We­ also­ gratefully­ acknowledge­ the­ efforts­ of­ IOM­ Anniversary­ Fellow,­ Roderick­ King,­ for­ reviewing­ early­ drafts­ of­ this­ summary­ and­ providing­helpful­advice. Finally,­we­would­like­to­thank­all­the­sponsors­who­make­the­Round­ table­on­Health­Disparities­a­reality.­Financial­support­for­this­Roundtable­ was­ provided­ by­ the­ Agency­ for­ Healthcare­ Research­ and­ Quality­ and­ the­ Office­ of­ Minority­ Health,­ U.S.­ Department­ of­ Health­ and­ Human­ Services;­ the­ California­ Endowment;­ the­ California­ HealthCare­ Founda­ tion;­ the­ Commonwealth­ Fund;­ the­ Connecticut­ Health­ Foundation;­ the­ Ford­Foundation;­the­Healthcare­Georgia­Foundation;­the­Henry­J.­Kaiser­ Family­ Foundation;­ Kaiser­ Permanente;­ Merck;­ the­ Missouri­ Foundation­ for­Health;­the­Robert­Wood­Johnson­Foundation;­and­the­W.­K.­Kellogg­ Foundation. Dr.­Nicole­Lurie,­Chair Roundtable­on­Health­Disparities

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List of Acronyms BRFSS Behavioral Risk Factor Surveillance System CBP community-based planning CBPR community-based participatory research CDC Centers for Disease Control and Prevention CEO chief executive officer CHW community health worker CLAS cultural and linguistically appropriate services CTSA Clinical Translational Science Award GAVI Global Alliance for Vaccines and Immunization HRSA Health Resources and Services Administration LISC Local Initiatives Support Corporation MTO Move to Opportunity NCHS National Center for Health Statistics NHANES National Health and Nutrition Examination Survey NIH National Institutes of Health REACH Racial and Ethnic Approaches to Community Health YRBS Youth Risk Behavior Survey xii

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