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Introduction

Although some attention is paid to the reduction of health disparities at the national level, information about successful efforts at the state and local levels is seldom heard. What are the policy levers that have led to successful state or local initiatives? To make progress at the national level, it is important to understand what has worked at other levels of government.

Similarly, successes in other nations might provide important lessons for the United States. For example, what is going on with health inequalities in England, where there is clear accountability and strong support for reducing health disparities?

The present workshop, then, was designed to focus on state and local policy initiatives to improve health disparities. The workshop also included information about efforts at reducing health disparities in England. There, health officials carefully look at the data to identify the drivers of health disparities. Once this has occurred, they then figure out who is responsible and who has leverage over those issues and then get local agencies to work together.

This workshop follows four earlier workshops convened by the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities. The first, held in St. Louis, Missouri, focused on the interface between the health care system and the community in which it is based. The second, held in Atlanta, Georgia, looked at issues of disparities across the life span, with a particular emphasis on young children. The third, held in Newport Beach, California, drew on the potential linkages between health literacy, health disparities, and quality improvement efforts. Finally, the fourth one, held in Los Angeles, California, investigated the role of



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1 Introduction Although some attention is paid to the reduction of health disparities at the national level, information about successful efforts at the state and local levels is seldom heard. What are the policy levers that have led to suc- cessful state or local initiatives? To make progress at the national level, it is important to understand what has worked at other levels of government. Similarly, successes in other nations might provide important lessons for the United States. For example, what is going on with health inequali- ties in England, where there is clear accountability and strong support for reducing health disparities? The present workshop, then, was designed to focus on state and local policy initiatives to improve health disparities. The workshop also included information about efforts at reducing health disparities in England. There, health officials carefully look at the data to identify the drivers of health disparities. Once this has occurred, they then figure out who is responsible and who has leverage over those issues and then get local agencies to work together. This workshop follows four earlier workshops convened by the Round- table on the Promotion of Health Equity and the Elimination of Health Disparities. The first, held in St. Louis, Missouri, focused on the interface between the health care system and the community in which it is based. The second, held in Atlanta, Georgia, looked at issues of disparities across the life span, with a particular emphasis on young children. The third, held in Newport Beach, California, drew on the potential linkages between health literacy, health disparities, and quality improvement efforts. Finally, the fourth one, held in Los Angeles, California, investigated the role of 1

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2 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES framing in addressing health disparities and the impact that the nation’s demographic changes are having on health disparities. The purpose of the Roundtable is to convene various groups of people and continue to have a dialogue. As a Roundtable is not a formal Insti- tute of Medicine committee, the members do not make recommendations. Workshops serve as a way to present and disseminate ideas to a broader audience of people, including policy makers, government agency staff, members of the health care workforce, and interested participants from the general public. SCOPE OF THE WORKSHOP On May 11, 2009, the Institute of Medicine’s Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities sponsored a public workshop to discuss the role of state and local policy initiatives in reducing health disparities. With the advent of health care reform at the federal level, it is all the more important that ways of reducing existing disparities and promoting health equity at the state and local levels be examined. Institutional policies, such as those created by health plans, should also be studied in conjunction with state and local concerns. In this summary, information about policies to reduce disparities within Kaiser Permamente and Allina Health System is also presented. The workshop, entitled State and Local Policy Initiatives to Reduce Health Disparities, was organized to look beyond federal initiatives to the state and local levels to learn more about what works. The hope is to advance the dialogue about health disparities by facilitating discussion among stakeholders in the community, academia, health care professions, business, policy-making entities, and philanthropic organizations. The goal of the meeting was to discuss how to highlight the importance of “com- munity” when ways to address health disparities are addressed. A focus on several different geographic areas could help identify commonalities in community strategies, best practices, and lessons learned from community successes and failures in addressing health disparities. WORKSHOP AGENDA The workshop began with the presentation of a paper commissioned by the Roundtable and authored by Larry Cohen, Rachel Davis, and Sharon Rodriguez of the Prevention Institute and Anthony Iton of the Alameda County Department of Public Health. Their paper, A Time for Opportunity: Local Solutions to Reduce Inequities in Health and Safety, outlines several dozen recommendations for reducing health disparities and promoting

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3 INTRODUCTION health equity at the local level. The full version of the paper can be found in Appendix A. The participants spent the rest of the morning hearing more about efforts being undertaken in Minneapolis, Minnesota, in particular and in the state of Minnesota in general. Minneapolis Mayor R. T. Rybak spoke about the changes taking place in Minneapolis at the community level, including efforts to create more affordable housing and supporting a local food movement. Gordon Sprenger, former chief executive officer of Allina Health Systems, gave the history of the development of the Allina Back- yard Project, an ambitious neighborhood-based program designed to create jobs and incorporate other structural changes into a plan to reduce health disparities. The final speaker of that morning, Sanne Magnan, who is the Commissioner of Health in Minnesota, presented data on health disparities at the state level and described plans being undertaken statewide to improve health equity. The afternoon sessions presented additional discussions of efforts at the state level as well as those at the national level in England. Annette Williamson of the Department of Health in England described the National Support Teams program, designed specifically to reduce infant mortality rates across that country. Although England has national health goals, the support teams at the local level can determine how best to meet those goals in their communities. Joel Weissman of the Executive Office of Health and Human Services in the Commonwealth of Massachusetts spoke about how state-level reforms have affected health disparities. The day concluded with reactions to the earlier presentations by a three-member panel: Winston Wong of Kaiser Permanente, Brian Smedley from the Joint Center for Political and Economic Studies, and Atum Azzahir of the Phillips-Powderhorn Cultural Wellness Center. These individuals shared their perceptions of the information presented throughout the day. Following this panel, Nicole Lurie, chair of the Roundtable, offered con- cluding remarks. The following is a summary of the presentations and discussions at the workshop and as such is limited to the views presented and discussed during the workshop. The broader scope of issues pertaining to this subject area is recognized but could not be addressed in this summary. Appendix B provides the workshop agenda, and Appendix C presents biographical sketches of all workshop presenters. KEY THEMES Throughout the workshop, speakers, and workshop participants high- lighted several recurring themes:

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4 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES • Residential segregation. Gentrification, urban renewal, and the his- torical practice of redlining (refusing to lend money to borrowers based upon race or refusing to lend money to purchase housing in an area with a high concentration of minorities) all affect where low-income people of color can live. This, in turn, affects their health. • Race and racism. Race interacts with the process of residential segregation and thus cannot be ignored when health outcomes are evaluated. • Lack of access to health care. Lack of access, especially for specialty care, is a major problem for people of color living in low-income communities. • Lack of community infrastructure. A lack of safe places to walk and exercise and a lack of access to large grocery stores in a com- munity affect the health of the residents in that community. These are important because skyrocketing obesity rates in some racial and ethnic minority groups are contributing to rising rates of chronic diseases, such as diabetes, which can be ameliorated by exercise and a healthy diet. • Other community factors. Poverty and violence are major contribu- tors to racial and ethnic health disparities. • Shorter life spans for future generations. Several speakers noted that if current trends continue, children born today will not live as long as their parents do. Studies of foreign-born immigrant chil- dren and U.S.-born children of immigrant parents indicate that the U.S.-born children will have shorter life spans than their parents. ORGANIZATION OF THE REPORT The report that follows summarizes the presentations and discussions that occurred during the workshop. Chapter 2 reviews the presentation and discussion of the commis- sioned paper, A Time for Opportunity: Local Solutions to Reduce Inequi- ties in Health and Safety. Chapter 3 describes the efforts made to reduce health disparities at the local level in Minneapolis and at the state level in Minnesota. Chapter 4 includes a set of introductory comments from Roundtable member Tom Granatir, followed by Annette Williamson’s presentation about efforts in England. Joel Weissman’s observations about the effects of health care reform at the state level follow. Finally, Chapter 5 describes the comments and observations of the reactor panel and the concluding com- ments of the Roundtable chair, Nicole Lurie.