3

Healthy People 2010: How Far Have We
Come in Reducing Health Disparities?

Howard Koh, in his role as assistant secretary for health at the U.S. Department of Health and Human Services (HHS), oversees a broad portfolio of public health activities and programs. He has also served as a clinician, a professor, and a state health commissioner in Massachusetts.

As the assistant secretary for health, Koh says that he values the importance of the World Health Organization (WHO) definition of health: “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 1946). It is unlikely, however, that many societies and countries are meeting this standard of health.

The racial and ethnic disparities in health and well-being that people of color in the United States experience are also often referred to as “inequities.” These inequities are a major challenge in public health today. Health disparities or inequities can be viewed through multiple lenses (Figure 3-1). The left of Figure 3-1 shows population variables, including race/ethnicity and socioeconomic status. The lens of geographic location is on the right. Diseases are at the top, and risk factors, both individual and environmental, are at the bottom. These lenses overlap, depending on a host of real-world conditions (Koh et al., 2010).

HEALTHY PEOPLE

The assistant secretary for health at HHS oversees Healthy People, a comprehensive framework for improving the health of all Americans. Koh gave a broad overview of the Healthy People Initiative, the updated frame-work,



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3 Healthy People 2010: How Far Have We Come in Reducing Health Disparities? H oward Koh, in his role as assistant secretary for health at the U.S. Department of Health and Human Services (HHS), oversees a broad portfolio of public health activities and programs. He has also served as a clinician, a professor, and a state health commissioner in Massachusetts. As the assistant secretary for health, Koh says that he values the impor- tance of the World Health Organization (WHO) definition of health: “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 1946). It is unlikely, however, that many societies and countries are meeting this standard of health. The racial and ethnic disparities in health and well-being that people of color in the United States experience are also often referred to as “inequi- ties.” These inequities are a major challenge in public health today. Health disparities or inequities can be viewed through multiple lenses (Figure 3-1). The left of Figure 3-1 shows population variables, including race/ethnicity and socioeconomic status. The lens of geographic location is on the right. Diseases are at the top, and risk factors, both individual and environmental, are at the bottom. These lenses overlap, depending on a host of real-world conditions (Koh et al., 2010). HEALTHY PEOPLE The assistant secretary for health at HHS oversees Healthy People, a comprehensive framework for improving the health of all Americans. Koh gave a broad overview of the Healthy People Initiative, the updated frame- 31

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32 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? By Disease Cancer Cardiovascular disease HIV/AIDS Diabetes Hepatitis Mental illness Oral health disorders By Population Race/ethnicity By Geography Socioeconomic position Urban versus rural Gender Developed versus developing countries Age Neighborhood segregation Disability By Risk Factor Sexual orientation Substance abuse (including tobacco) Diet and weight Vaccination status Screening status Access to care Insurance status Risk of injury/violence Environmental risks Sexual behavior Physical inactivity FIGURE 3-1 Multiple and overlapping lenses for viewing health disparities. SOURCE: Koh et al. (2010). work, and an overview of data regarding several Healthy People health indicators. Healthy People began in 1979 under Julius Richmond, then assistant secretary for health and surgeon general. The document sets out health goals for the nation, and the framework is updated every 10 years. In 2010, Healthy People 2010 (HHS, 2000) concluded a decade of an inclu- sive public process that reflected input and feedback from a diverse group of individuals and organizations nationwide. With 28 focus areas and 467 specific objectives, Healthy People 2010 had two overarching goals: first, to improve both the quantity and the quality of life and, second, to eliminate health disparities. Box 3-1 identifies the 10 leading health indicators, which cover 31 objectives. Preliminary findings show that over the past decade progress toward or achievement of the targets has occurred for about half of these objectives. In another analysis of the leading health indicators in Healthy People 2010, Sondik and colleagues (2010) evaluated progress toward meeting the targets. They concluded that “although some progress has been made, there is much work to be done toward the Healthy People 2010 targets

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33 HEALTHY PEOPLE 2010 BOX 3-1 Leading Health Indicators Ten indicators (31 objectives): • Access to health care • Environmental quality • Immunization • Injury and violence • Mental health • Overweight and obesity • Physical activity • Responsible sexual behavior • Substance abuse • Tobacco use Preliminary findings show that over the past decade progress toward or meeting of the targets has occurred for about half of these objectives. SOURCE: HHS (2000). and both overarching goals” (p. 271). More specifically, they noted that no significant change in disparities had occurred for at least 70 percent of the leading health indicator objectives. The group seeing the fewest advances was American Indians/Alaska Natives. A number of examples provide evidence of these disparities. Life expec- tancy (Figure 3-2) has steadily increased since 1970, although major dis- parities remain. African American males have the shortest life expectancy of all groups in Figure 3-2. HIV infection/AIDS is another area in which large disparities exist (Figure 3-3). African American men are at a particularly high risk of dying from HIV infection, despite the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s. For mortality rates due to coronary heart disease, the Healthy People 2010 target of 162 deaths per 100,000 was met for all groups except African Americans. Heart disease remains the number one killer in the United States; however, African Americans have higher rates of mortality from coronary heart disease than other groups. Figure 3-4 shows the gap between the group with the highest rate of mortality (African Americans) and the group with the lowest (Asians); this gap needs to be narrowed going forward, Koh said. As Figure 3-4 demonstrates, the gap between the groups with the highest and lowest rates of mortality from coronary heart disease has remained constant over time.

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34 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? Life Expectancy in Years FIGURE 3-2 Life expectancy. SOURCE: Arias et al. (2010). Figure 3-2, fixed image, color Deaths per 100,000 Population FIGURE 3-3 Rates of death from HIV infection and introduction of highly active antiretroviral therapy (HAART).color, fixed image Figure 3-3, SOURCE: NCHS (2010).

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35 HEALTHY PEOPLE 2010 Decrease desired Deaths per 100,000 Standard Population Black 2010 Target: 162 Total White Hispanic American Indian Asian FIGURE 3-4 Rates of mortality from coronary heart disease. NOTES: Data are age-adjusted to the 2000 standard are fixed image American Indian Figure 3-4, color, some editable text, rules population. includes Alaska Native. Asian includes Pacific Islander. The black and white cat- egories exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. Only one race category could be recorded. SOURCE: Heron and Tejada-Vera (2009). Mammography rates by race/ethnic group represent a piece of good news. The gap between the group with the highest rate of mammography screening (whites) and the group with the lowest (as of 2010, Latinos) has narrowed over time. However, the picture changes when rates of mam- mography are examined by socioeconomic status (Figure 3-5). The rates for poor and near-poor women are still far too low, especially compared with those for middle- and high-income women. Data from the National Vaccine Program Office indicate that racial/eth- nic disparities in childhood immunization rates have narrowed significantly since the mid-1990s. The same narrowing in adult immunization rates has not been seen, however. Much current attention is focused on the trend of increased rates of obesity in the United States. Figure 3-6 clearly indicates not only how far the nation is from meeting the target, but also that the trends are worsening instead of improving. The issue of combating obesity will be discussed in more detail later in this summary. Figure 3-7 provides data for another area in which the target has not been met—health insurance coverage rates. Latinos are the population group that is least likely to be insured. This finding that Latinos have the

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36 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? 2010 Target: 70% White Black Total Asian Hispanic American Indian Increase desired 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 FIGURE 3-5 Rates of mammography screening from 1997 to 2009. NOTES: Data are Figure 3-5, color,40 years and older who received a mammo- for women aged rules are fixed images gram within past 2 years. Data are age-adjusted to the 2000 standard population. American Indian includes Alaska Native. The black and white categories exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. Only one race category could be recorded. SOURCE: NCHS (2010). Decrease desired 2010 Target: 15% Total Mexican Black White Female Male American Gender Race/ethnicity FIGURE 3-6 Obesity among adults ages 20 years and over. NOTES: I = 95% confidence interval. Data are for adults aged 20 years and over 1 and are age-adjusted to theFigure 3-6 color, xed images, some text editable 2000 standard population using the age groups 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80 years and over. Obesity is defined as BMI ≥ 30.0. The black and white categories exclude persons of Hispanic origin. Per- sons of Mexican American origin may be any race. Prior to 1999, respondents were asked to select one race category; selection of more than one race was not an option. For 1999 and later years, respondents were asked to select one or more races. Data for the single race categories are for persons who reported only one racial group. SOURCE: NHIS (2010).

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37 HEALTHY PEOPLE 2010 2010 Target: 100% White Asian Total Black Native American Hawaiian Indian Hispanic Increase desired FIGURE 3-7 People with health insurance. NOTES: Data are for adults under age 65 years who have any public or private health insurance. American Indian includes Alaska Native, and Native Hawaiian includes Pacific Islander. The categories black and white exclude persons of His- panic origin. Persons of Hispanic origin may be any race. Respondents were asked Figure 3-7, fixed image, some text editable to select one race prior to 1999. For 1999 and later years, persons were asked to select one or more races. Data for the single race categories shown are for persons who reported only one racial group. SOURCE: NHIS (2010). highest rates of uninsurance of all racial and ethnic groups remains true in Massachusetts, even after passage of health care reform legislation in that state (IOM, 2011). Koh raised the question of how changes should be made to achieve these objectives. One suggestion is to focus on translating research results into effective community programs. This is the science of implementation and dissemination. “We need to focus on maintaining and sustaining prog- ress over many generations,” said Koh. These are all issues now relevant to the recent launch of Healthy People 2020. One strategy for maintaining and sustaining progress is to use the RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) evaluation framework (see Table 3-1) for the translation of findings from research on efficacy (evaluated by use of interventions delivered under optimum conditions) into findings on effec- tiveness in the community (evaluated by use of interventions delivered under real-world conditions) (Glasgow et al., 2003).

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38 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? TABLE 3-1 RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) for Translating Research Efficacy into Community Effectiveness Reach: Efficacy/ Adoption: I mplementation: Maintenance: Participation Effectiveness: Number of and Quality and How long RE-AEIM rate and Effect of an representative- consistency with intervention representative- intervention on ness of settings which interven- holds up ness of specified and interven- tion is delivered participants outcomes tionists Research Settings Efficacy (Limited Homogenous Intense One setting By research staff Few or no sample specialized issues intervention Community Settings) Effectiveness (Broad Multiple By variety of Major issues Heterogeneous Brief, feasible settings people sample intervention SOURCE: Howard Koh presentation to the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities, April 2010, Washington, DC. Modified from Glasgow et al. (2003). HHS AND EFFORTS TO REDUCE DISPARITIES Koh’s final comments outlined the efforts of HHS to address dispari- ties in health. First, Medicare has paid increased attention to health dis- parities through the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. MIPPA requires HHS to concentrate more effort on data collection, measurement, and evaluation of health disparities. Second, the Agency for Healthcare Research and Quality (AHRQ), to be discussed in more detail later in this summary, is the entity within HHS responsible for its biennial National Healthcare Disparities Report. The most recent report, for 2009, was released in early 2010 (AHRQ, 2010). Third, the American Recovery and Reinvestment Act (ARRA) of 2009 also contained provisions relevant to attainment of reductions in health disparities. The Communities Putting Prevention to Work (CPPW) initiative focuses on community-based interventions that affect social determinants. The legislation also made significant investments in community health cen-

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39 HEALTHY PEOPLE 2010 ters. Finally, ARRA contained funding for patient-centered health outcomes research (PCORI). The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 establishes a national committee that is looking at ways to track race, ethnicity, and primary language data through electronic data collection methods. This legislation also promotes increased use of electronic health records and specifically provides funding for the Indian Health Service to assist with health information technology adoption. HHS AND HEALTH CARE REFORM Koh briefly reviewed health reform measures at HHS and their relation to the goal of promoting health equity. The passage of the health care reform legislation in 2010, the ACA, also addresses health disparities. First, the act expands on Office of Management and Budget standards and directs that more emphasis be placed on the dedicated collection of data on race, ethnic- ity, gender, and the primary language spoken. Second, the National Center on Minority Health and Health Disparities, within the National Institutes of Health, is elevated to the level of an institute—the National Institute on Minority Health and Health Disparities. Additionally, four new offices of minority health are in development within HHS, which will assist in the coordination of disparities reduction efforts. The legislation also mandates a study of value-based purchasing programs, including programs for Medicare populations, by race/ethnicity. HHS AND PREVENTION Koh noted that the ACA also contains a number of important provi- sions directed to the promotion of prevention. Perhaps the most important provision is that the legislation established the new Prevention Trust Fund, funded at $500 million for fiscal year 2010, with that amount expected to rise in coming years. Other components of the ACA that promote prevention include the following: • New private health insurance plans must cover the high-value prevention recommendations of the U.S. Preventive Services Task Force (USPSTF) as well as the recommendations of the Advisory Committee on Immunization Practices (ACIP). • Medicaid must also encourage states to cover the USPSTF and ACIP recommendations.

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40 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? • Medicaid must cover the costs of comprehensive tobacco cessation programs for pregnant women. • A no-cost-share rule for preventive services was established for Medicare and went into effect on January 1, 2011. In addition, the HHS Health Disparities Council, co-chaired by Howard Koh and Sherry Glied, assistant secretary for planning and evaluation, was established under the ACA. The goal of the council is to coordinate activities across departments and to develop the infrastructure necessary to promote activities directed at attainment of reductions in health disparities. Another new activity is the National Partnership for Action to End Health Disparities (NPA). Coordinated by the Office of Minority Health, HHS released two guiding documents in response to the NPA Call to Action: • The National Stakeholder Strategy for Achieving Health Equity provides “an overarching roadmap for eliminating health dispari- ties through cooperative and strategic actions” (OMH, 2011, p. 1). The strategy includes the collection of ideas and suggestions from thousands of people who offer comments. The focus is to encour- age public- and private-sector partnerships to support community- driven approaches to achievement of health equity. • The HHS Action Plan to Reduce Racial and Ethnic Health Dis- parities is designed to be used in coordination with the stakeholder report to address national goals to eliminate health disparities and to build upon the objectives of Healthy People 2020. The vision of the Action Plan is to attain “a nation free of disparities in health and health care” (OASH, 2011, p. 11). Koh closed his comments by indicating the need for a focus on leader- ship in health equity activities (Koh and Nowinski, 2010). In an ambiguous and multidisciplinary world, it is critical to promote a “health in all poli- cies” approach. This means working across agencies and engaging agencies such as the U.S. Departments of Justice, Education, and Transportation to address health equity. The ultimate goal is to renew a sense of community dedicated to prevention and public health and to eliminate health dispari- ties in the future. REFERENCES AHRQ (Agency for Healthcare Research and Quality). 2010. National Healthcare Disparities Report 2009. Rockville, MD: Agency for Healthcare Research and Quality.

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41 HEALTHY PEOPLE 2010 Arias, E., B. L. Rostron, and B. Tejada-Vera. 2010. United States life tables, 2005. National Vital Statistics Reports 58(10). Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention. Glasgow, R. E., E. Lichtenstein, and A. C. Marcus. 2003. Why don’t we see more transla- tion of health promotion research into practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health 93(8):1261-1267. Heron, M. P., and B. Tejada-Vera. 2009. Deaths: Leading causes for 2005. National Vital Statistics Reports 58(8). Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention. HHS (Department of Health and Human Services). 2000. Healthy People 2010: Understand- ing and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office. IOM (Institute of Medicine). 2011. State and Local Policy Initiatives to Reduce Health Dis- parities: Workshop Summary. Washington, DC: The National Academies Press. Koh, H. K., and J. M. Nowinski. 2010. Health equity and public health leadership. American Journal of Public Health 100(Suppl. 1):S9-S11. Koh, H. K., S. C. Oppenheimer, S. B. Massin-Short, K. M. Emmons, and A. G. Geller. 2010. Translating research evidence into practice to reduce health disparities: A social determi- nants approach. American Journal of Public Health 100(Suppl. 1):S72-S80. NCHS (National Center for Health Statistics). 2010. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention. NHIS (National Health Interview Survey). 2010. Sample Adult Core Component. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention. OASH (Office of the Assistant Secretary for Health). 2011. HHS Action Plan to Reduce Racial and Ethnic Health Disparities: A Nation Free of Disparities in Health and Health Care. Washington, DC: Office of the Assistant Secretary for Health. OMH (Office of Minority Health). 2011. National Stakeholder Strategy for Achieving Health Equity. Washington, DC: Office of Minority Health. Sondik, E. J., D. T. Huang, R. J. Klein, and D. Satcher. 2010. Progress toward the Healthy People 2010 goals and objectives. Annual Review of Public Health 31:271-281. WHO (World Health Organization). 1946. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

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