DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA

Implications for Framing Health Disparities

Workshop Summary

Karen M. Anderson, Rapporteur

Roundtable on the Promotion of Health Equity and the Elimination of 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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DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA Implications for Framing Health Disparities Workshop Summary Karen M. Anderson, Rapporteur Roundtable on the Promotion of Health Equity and the Elimination of 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. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by contracts between the National Academy of Sciences and Agency for Healthcare Research and Quality and the Office on Minority Health (Award No. HHSP23320042509X1); The California Endowment (Contract No. 20052634); California Health Care Foundation (Award No. 06-1213); The Commonwealth Fund (Award No. 20060048); Connecticut Health Foundation (unnumbered); Directors of Health Promotion and Education (unnumbered); Healthcare Georgia Foundation (unnumbered); the Henry J. Kaiser Family Foundation (Award No. 01-1149-810); Kaiser Permanente (Award No. 20072164); W.K. Kellogg Foundation (Award No. P0123822); Merck & Co., Inc. (unnum- bered); the Missouri Foundation for Health (Award No. 08-0006-HPC-08); and Robert Wood Johnson Foundation (Award No. 56387). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for this project. This summary is based on the proceedings of a workshop that was sponsored by the Round- table on the Promotion of Health Equity and the Elimination of Health Disparities. It is prepared in the form of a workshop summary by and in the name of the rapporteur as an individually authored document. International Standard Book Number-13: 978-0-309-14886-3 International Standard Book Number-10: 0-309-14886-3 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 2010 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). 2010. Demographic Changes, a View from California: Implications for Framing 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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MEMbERS OF THE PLANNINg COMMITTEE1 NICOLE LURIE2 (Chair), RAND Corporation, Arlington, VA MILDRED THOMPSON (Co-Chair), PolicyLink, Oakland, CA AMERICA bRACHO, Latino Health Access, Anaheim, CA WILLIAM F. CRIMI, The Connecticut Health Foundation, New Britain, CT JAMILA DAVISON, University of California, Los Angeles ALICIA DIXON, The California Endowment, Los Angeles, CA CARA V. JAMES, Henry J. Kaiser Family Foundation, Washington, DC JAMES KRIEgER, University of Washington, Seattle, WA SAMUEL SO, Stanford University, Stanford, CA WILLIAM A. VEgA, David Greffen School of Medicine, University of California, Los Angeles WINSTON F. WONg, Kaiser Permanente, Oakland, CA 1 Institute of Medicine planning committees are solely responsible for organizing the work- shop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. 2 Resigned June 2009. 

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ROUNDTAbLE ON THE PROMOTION OF HEALTH EqUITy AND THE ELIMINATION OF HEALTH DISPARITIES1 NICOLE LURIE2 (Chair), RAND Corporation, Arlington, VA MILDRED THOMPSON (Co-Chair), PolicyLink, Oakland, CA VICTORIA HOLLOWAy bARbOSA, Dermal Insights, Inc., Chicago, IL ANNE C. bEAL, The Commonwealth Fund, New York, NY CHERyL A. bOyCE, Ohio Commission on Minority Health, Columbus, OH AMERICA bRACHO, Latino Health Access, Anaheim, CA FRANCIS D. CHESLEy, Agency for Healthcare Research and Quality, Rockville, MD TODD COX, Ford Foundation, New York, NY WILLIAM F. CRIMI, The Connecticut Health Foundation, New Britain, CT ALICIA DIXON, The California Endowment, Los Angeles, CA JOSÉ J. ESCARCE, University of California, Los Angeles gARTH N. gRAHAM, Department of Health and Human Services, Rockville, MD TOM gRANATIR, The Innovation Center, Humana, Inc., Chicago, IL CARA V. JAMES, Henry J. Kaiser Family Foundation, Washington, DC JENNIE R. JOE, College of Medicine, University of Arizona, Tucson, AZ JAMES R. KIMMEy, Missouri Foundation for Health, St. Louis, MO HOWARD K. KOH, Harvard School of Public Health, Boston, MA JAMES KRIEgER, University of Washington, Seattle, WA ANNE C. KUbISCH, The Aspen Institute, New York, NY JEFFREy LEVI, Trust for America’s Health, Washington, DC JOHN C. LEWIN, American College of Cardiology, Washington, DC JANE ISSACS LOWE, The Robert Wood Johnson Foundation, Princeton, NJ RICHARD K. MURRAy, Merck & Co., Inc., North Wales, PA gARy D. NELSON, Healthcare Georgia Foundation, Atlanta, GA SAMUEL NUSSbAUM, WellPoint, Inc., Indianapolis, IN MICHAEL W. PAINTER, The Robert Wood Johnson Foundation, Princeton, NJ DAVID P. PRyOR, Aetna, Inc., Thousand Oaks, CA STEVE M. PU, Missouri Foundation for Health, Kennett, MO KyU RHEE, Department of Health and Human Services, Rockville, MD 1 Institute of Medicine 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. 2 Resigned June 2009. i

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MARK D. SMITH, California Health Care Foundation, Oakland, CA PATTIE TUCKER, Centers for Disease Control and Prevention, Atlanta, GA WINSTON F. WONg, Kaiser Permanente, Oakland, CA TERRI D. WRIgHT, W.K. Kellogg Foundation, Battle Creek, MI Board on Population Health and Public Health Practice Liaisons, Institute of Medicine SAMUEL SO, Stanford University, Stanford, CA WILLIAM A. VEgA, David Greffen School of Medicine, University of California, Los Angeles Study Staff KAREN M. ANDERSON, Senior Program Officer ROSE MARIE MARTINEz, Board Director THELMA L. COX, Senior Program Assistant (April 2008 through January 2009) PAMELA A. LIgHTER, Senior Program Assistant (February 2009 through present) PATRICK bURKE, Financial Officer (October 2008 through October 2009) AMy M. PRzybOCKI, Financial Officer (Noember 2009 through present) HOPE HARE, Administrative Assistant ii

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Reviewers This report has been reviewed in draft form by persons 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 confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Jamila Davison, School of Medicine, Emory University John C. Lewin, American College of Cardiology Steve Pu, Missouri Foundation for Health Pattie Tucker, Centers for Disease Control and Prevention Larry Wallack, College of Urban and Public Affairs, Portland State University Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by bobbie berkowitz. Appointed by the National Research Council, she was responsible for mak- ing 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 authoring committee and the institution. ix

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Contents PREFACE xv 1 INTRODUCTION 1 Scope of the Workshop, 1 Workshop Agenda, 2 Key Themes, 3 Organization of the Report, 4 2 THE CHANGING FACE OF AMERICAN COMMUNITIES: IMPLICATIONS FOR FRAMING DISCUSSIONS ABOUT HEALTH DISPARITIES 5 “No Data, No Problem,” 5 Change in American Communities, 5 Reaction and Discussion, 11 Unity or Apartheid?, 12 The Myth System of Apartheid, 13 Redlining, 14 Collective Consciousness, 18 Reaction and Discussion, 19 References, 20 3 FRAMING HEALTH DISPARITIES 23 Framing Public Health Issues, 24 The Default Frame: Rugged Individualism and Personal Responsibility, 27 xi

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xii CONTENTS The Role of the Media, 28 Steps Toward Reframing Health Disparities, 29 References, 30 4 HOW HAVE CALIFORNIA COMMUNITIES IN TRANSITION FRAMED HEALTH DISPARITIES FOR ACTION? 33 East Palo Alto, 33 Luisa Buada, R.N., M.P.H., Chief Executive Officer, Ravenswood Family Health Center, South County Community Health Center, Inc., 33 Melieni Talakai, R.N., Vice-Chair, Board of Directors, Ravenswood Family Health Center, 35 Ruben Abrica, City Council Member, East Palo Alto City Council, 36 Douglas Fort, For Youth, By Youth, Founder and Director, Intervention/ReEntry/Street Team Services, 37 Discussion, East Palo Alto, 38 Fresno, 38 Keith Kelley, President and Chief Executive Officer, Fresno West Coalition for Economic Development, 38 Lue N. Yang, Fresno Center for New Americans, 40 Genoveva Islas-Hooker, M.P.H., Regional Program Coordinator, Central California Regional Obesity Prevention Program, 41 South Los Angeles, 42 Maxine Liggins, M.D., Area Medical Director, Los Angeles County Department of Public Health, 42 Richard Veloz, J.D., M.P.H., Chief Executive Officer, South Central Family Health Center, 46 Marqueece Dawson, Executive Director, Community Coalition, 48 Discussion, South Los Angeles, 50 Tony Iton, Discussant, 50 Presentation Themes, 50 The BARHII Framework, 54 Open Discussion, 56 References, 57 5 DISCUSSION AND MOVING FORWARD 59 Breakout Sessions, 59 Working Across Racial and Ethnic Groups, 60 The Importance of Framing, 60 Systemic Issues, 60 Apartheid?, 62 Disparities That Need to Be Addressed, 63 Moving Forward, 63

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xiii CONTENTS APPENDIXES A Agenda 65 B Speaker Biographies 69 C Resources 77 TAbLES AND FIgURES Tables 2-1 New Populations and Communities Established Throughout the Country by Deep Demographic Changes, 6 4-1 Population Health Status, 43 4-2 Health Care Access, 44 4-3 Health-Related Quality of Life, 44 4-4 Prevention and Health Outcomes, 45 4-5 Years of Potential Life Lost, 45 Figures 2-1 Percent of children who have not seen a dentist by age 11, 8 2-2 Mammogram screening and Pap test rates differ among women by Asian ethnic subgroup, 9 2-3 Age-adjusted diabetes prevalence by race and ethnicity, adults ages 18 years and over, 2005, 10 2-4 Percent obese as a function of RFEI using urbanicity—specific buffers, adults age 18 and over, California, 2005, 12 2-5 Redlining of Philadelphia, 15 2-6 Movements of different ethnic groups in Pittsburgh, Pennsylvania, from 1930 to 1995, 16 2-7 The Plan, 18 3-1 Example of the importance of external or environmental cues, 25 3-2 Different responses to two variations of the same question, 26 4-1 Los Angeles County prevalence of health disparities, 47 4-2 Framework for understanding and measuring health inequities, 55

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Preface Since early 2007, the Roundtable has met with the objectives of increas- ing the visibility of racial and ethnic health disparities as a national problem, furthering the development of programs and strategies to reduce disparities, fostering the emergence of leadership on this issue, and tracking promising activities and developments in minority care that could lead to the reduc- tion or elimination of disparities. The Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities includes represen- tatives from the health professions, federal, state, and local government, foundations, academia, managed care organizations, advocacy groups, and community-based organizations. Its mission is to facilitate communication across sectors and—above all—to generate action. Through its convening capacity and by holding public workshops across the nation, the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities aspires to advance understanding of health disparities and explore solutions for ending them. In doing so, it endeavors to make a lasting contribution to the quality of life for some of this country’s most vulnerable groups. With this goal in mind, on July 28, 2008, the Roundtable on the Promo- tion of Health Equity and the Elimination of Health Disparities convened a workshop in Los Angeles, California, America in Transition, a View from California: Implications for Addressing Health Disparities. By focusing on the complexities of immigration in the country’s most populous state, Cali- fornia, the Roundtable looked at how the discussion of “framing” health disparities can influence the actions that are taken in response. x

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xi PREFACE ACKNOWLEDgMENTS The Roundtable on the Promotion of Health Equity and the Elimi- nation of Health Disparities thanks all workshop participants for their individual contributions to this workshop. Their willingness to share their time and expertise led to frank discussions about immigration, demographic changes, and the role of “framing” in highlighting health disparities for the public. We especially want to give thanks to Alicia Dixon, our project officer for The California Endowment. The workshop took place at The Califor- nia Endowment’s Center for Healthy Communities. Thanks to Alicia and the other California Endowment staff, especially George Kim and Jessica Lieder, for ensuring that the workshop ran smoothly. Thanks also to all of our speakers and panelists. Biosketches for all presenters can be found in Appendix B. The Roundtable members also thank the Institute of Medicine staff for their ongoing efforts to support the work of the Roundtable. Sincere gratitude is extended to Dr. Rose Marie Martinez, Director, Board on Population Health and Public Health Practice; Karen Anderson, for plan- ning, organizing, and implementing this workshop; and Thelma Cox, for managing all of the administrative components of the meeting. We also want to thank Patrick Burke and Hope Hare for their ongoing assistance and support. Thanks to the planning committee that worked so diligently on arrang- ing the workshop: Rajni Banthia, America Bracho, Will Crimi, Jamila Davison, Cara James, Jim Krieger, Rose Marie Martinez, Sam So, Mildred Thompson, Bill Vega, and Winston Wong. Several Robert Wood Johnson Clinical Scholars volunteered as scribes during the breakout sessions in the afternoon (Rhondee Benjamin-Johnson, Nazleen Bharmal, Anisha Patel, Rashmi Shetgiri, and Kara Odom Walker). Thanks to all for your assistance during the workshop. Finally, special thanks go to all of the sponsors who make the Round- table on the Promotion of Health Equity and the Elimination of Health Disparities a reality. Financial support for the Roundtable and its activities was provided by the Agency for Healthcare Research and Quality in the Department of Health and Human Services; The California Endowment; the California Health Care Foundation; the Centers for Disease Control and Prevention in the Department of Health and Human Services; The Commonwealth Fund; the Connecticut Health Foundation; the Healthcare

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xii PREFACE Georgia Foundation; the Henry J. Kaiser Family Foundation; Kaiser Perma- nente; Merck & Co., Inc.; the Missouri Foundation for Health; the Robert Wood Johnson Foundation; and the W.K. Kellogg Foundation. Nicole Lurie, Chair Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities

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