This week we highlight federal initiatives that are working to advance policies and programs that can make an impact on health and other outcomes and are taking an intersectional lens to our present challenges. These federal efforts, along with new research that showcases the importance of primary care to address our behavioral health crisis and other promising interventions, provide important insights on actions we can collectively take to achieve health equity throughout the country. While new research has shown areas of progress and opportunity, other studies demonstrate and reinforce where we have fallen short.
Protect Our Care is dedicated to making high-quality, affordable and equitable health care a right, and not a privilege, for everyone in America. We advocate for policies that lower health care costs and strengthen coverage, which are critical to expanding access to quality health care and, ultimately, achieving better health outcomes, particularly for people of color, rural Americans, LGBTQI+ individuals, people with disabilities, and more. Our strategies are driven by a broader commitment to tackling systemic inequities that persist due to racism and discrimination and the reality that multi-sector policies are needed to address basic conditions that affect health and related outcomes, particularly for marginalized communities.
INITIATIVES
Smart Cities Dive: President Biden Signs Executive Order on Promoting Racial Equity. “President Joe Biden signed an executive order on Thursday directing federal agencies to create annual, publicly-available Equity Action Plans that evaluate and ‘address the barriers underserved communities may face in accessing and benefitting from the agency’s policies, programs, and activities.’ Advocates for racial equality heralded the measure as a step in the right direction. As part of the federal initiative, the Department of Housing and Urban Development opened a portal allowing local governments to request technical assistance for its Thriving Communities program to help align their housing needs with their infrastructure investments under 2021’s bipartisan infrastructure law. Other initiatives include advancing equitable procurement, improving data equity and transparency, boosting economic development in rural communities and addressing emerging civil rights concerns such as biased algorithms in AI.” [Smart Cities Dive, 2/17/23]
American Hospital Association: HHS Hosts Black Health Matters Summit to Promote Racial Equity. “The Department of Health and Human Services today hosted the first daylong HHS Black Health Summit in Washington, D.C., where department officials highlighted federal, state and local efforts to eliminate health disparities and HHS resources to help advance health equity. Health and Human Services Secretary Xavier Becerra welcomed attendees and heralded the Biden Administration’s progress boosting Affordable Care Act enrollment and vaccine uptake among communities of color. Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure and Rep. Lauren Underwood, D-Ill., author of comprehensive maternal health legislation, discussed efforts to reduce Black maternal mortality and morbidity. Additionally, Miriam Delphin-Rittman, administrator of the Substance Abuse and Mental Health Services Administration, and Keisha Lance Bottoms, senior advisor to the president for public engagement, emphasized the importance of faith-based and other community partnerships in eradicating stigma and improving access to mental health treatment. The event concluded with a grants workshop featuring representatives from eight HHS agencies, including the National Institutes of Health, Administration for Children and Families, and Health Resources and Services Administration.” [AHA, 2/22/23]
Healthcare Finance News: Announcement of Medicare Benefit Expansion Mobility Devices will Help Address Disability Inequities. “The Centers for Medicare and Medicaid Services [CMS] has released a proposed National Coverage Determination on power seat elevation equipment on wheelchairs. This is the first National Coverage Determination to expand Medicare coverage for power seat elevation equipment on Group 3 power wheelchairs to allow individuals to have an easier transfer from the wheelchair to other surfaces. Group 3 power wheelchairs are designed to meet the needs of people with severe disabilities such as stroke, Amyotrophic Lateral Sclerosis and late-stage Parkinson’s or Multiple Sclerosis. The National Coverage Determination proposal incorporates feedback from interested parties, particularly those who are focused on eliminating health disparities for people with disabilities, CMS said. CMS encourages comments from all interested parties, but in particular, people with Medicare and their families, providers, clinicians, consumer advocates, healthcare professional associations and from individuals serving populations facing disparities in health and healthcare. Additionally, CMS is specifically interested in gathering additional scientific literature that provides evidence surrounding the medical necessity for seat elevation systems through studies that include measurable characteristics related to the performance of transfers.” [Healthcare Finance News, 2/16/23]
WRAL News: How Medicaid Expansion in North Carolina Will Help Rural Residents. “[R]ural Americans are more likely to die prematurely from heart disease, cancer, lung disease, and stroke, according to the National Institutes of Health (NIH). The NIH also reports that the risk of fatal car crashes, suicide, and drug overdoses is also higher in rural communities. Those trends are colliding with the rising number of rural hospitals closing their doors. North Carolina alone has lost 11 hospitals with between six and 70 inpatient beds since 2006, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Research from the 2019 Budget and Tax Center Report conducted by the North Carolina Justice Center indicates that Medicaid expansion would improve the physical and economic health of rural communities, as well as the hospitals that serve them. One study found that Medicaid expansion was associated with nearly 12 fewer deaths per 100,000 adults each year in states that have expanded Medicaid. In addition, according to the Commonwealth Fund, most Medicaid enrollees report higher rates of satisfaction than people with private insurance. Expanding Medicaid also helps rural hospitals by reducing the amount of uncompensated care they give. In Michigan, the cost of uncompensated care for uninsured people was cut in half after the state expanded Medicaid, a result seen across the country where states have adopted the program. By reducing that barrier to opening and growing a small business, the North Carolina Rural Center [also] projects that expanding Medicaid would create 83,000 jobs in North Carolina.” [WRAL News, 2/14/23]
Washington Post: Family Medicine May be a Factor in Improving Mental Health. “Primary care providers are at the forefront of the nation’s deepening behavioral health crisis because when patients walk into a doctor’s office, they bring all their needs with them. Asthma. Anxiety. Diabetes. Depression. Sniffles. Stress. A growing number of providers — like those at Charles Drew — are integrating behavioral health and primary care to improve the continuity of treatment and lower barriers to access. Now, the federal government is trying to bring down those barriers, too, by awarding 24 medical schools and hospitals a total of $60 million to train the next generation of primary care physicians — family medicine doctors, pediatricians, internists — to address behavioral health needs. Although behavioral and physical health are deeply intertwined, the two forms of care are often siloed in a poorly coordinated system. And patients often fall through the cracks of the disjointed system when they are referred to an outside specialist. The goal is to give people the space to share and to ensure they’re heard, [Sarah Abdelsayed] said, noting that it was common for appointments to last about an hour in her Buffalo offices after a racially motivated mass killing at a supermarket in a predominantly Black neighborhood in the city. If patients need support beyond what primary care providers can offer, they don’t have to go somewhere else to get it with an integrated care model, often on-site. In such a setting, there’s a behavioral health team, social workers, therapists or psychiatrists often. Experts say this helps foster discretion and dignity, because people could be sitting in a waiting room for myriad reasons.” [Washington Post, 2/10/23]
McDermott Plus: Select Telehealth Flexibilities Extended Under Act. “The Consolidated Appropriations Act, 2023 (2023 CAA) (Public Law 117-328), signed into law on December 29, 2022, funds US government operations for fiscal year 2023 and provides roughly $1.7 trillion in overall spending. The 2023 CAA extends certain key telehealth flexibilities instituted during the public health emergency (PHE) through December 31, 2024, effectively untying these flexibilities from the continued existence of the PHE. While the 2023 CAA decouples the extension of many telehealth flexibilities from the PHE and provides extended coverage through December 31, 2024, other telehealth policies remain tied to the PHE and will expire if additional legislative or regulatory action is not taken. The Administration announced on January 30, 2023, its intent to end the PHE on May 11, 2023.” [McDermott Plus, February 2023]
Futurity: The ACA Has Helped Farm Workers Get and Stay Healthy. “More than 2.5 million agricultural workers help maintain the United States’ abundant food supply. They play a vital role in the economy, but their job is hard and often dangerous. This low-income, largely immigrant workforce has some of the worst health outcomes in the US. Traditionally, farm workers have had difficulty getting routine preventive care because they’re often itinerant, working for a succession of employers who don’t provide health benefits. In the new paper, Donkor and colleagues conclude that Obamacare is helping farmworkers in a significant way—while also reducing economic stress on the health care system. The researchers found Obamacare has not only substantially raised the share of seasonal farm workers with medical insurance, it also has increased their use of preventive medical care and decreased their use of hospitals, including emergency care. The [Affordable Care Act] ACA also reduced the likelihood of a farm worker forgoing medical care. Medicaid-eligible farm workers were nearly 19% less likely to go without care; those eligible for an insurance subsidy under the law were nearly 9% less likely. Hospital use, including emergency room visits, decreased by 4.4% for Medicaid-eligible farm workers and 1.5% for those eligible for subsidies. These effects didn’t significantly differ between people with and without preexisting conditions, which suggests that the ACA has benefited farm workers’ health across the board.” [Futurity, 2/24/23]
CHALLENGES
Washington Post: CDC Finds Teenage Girls Are Experiencing Increasingly High Rates of Violence and Suicide. “Nearly 1 in 3 high school girls reported in 2021 that they seriously considered suicide — up nearly 60 percent from a decade ago — according to new findings from the Centers for Disease Control and Prevention. Almost 15 percent of teen girls said they were forced to have sex, an increase of 27 percent over two years and the first increase since the CDC began tracking it. Almost 3 in 5 teenage girls reported feeling so persistently sad or hopeless almost every day for at least two weeks in a row during the previous year that they stopped regular activities — a figure that was double the share of boys and the highest in a decade, CDC data showed. Girls fared worse on other measures, too, with higher rates of alcohol and drug use than boys and higher levels of being electronically bullied, according to the 89-page report. Thirteen percent had attempted suicide during the past year, compared with 7 percent of boys. Richard Weissbourd, a psychologist and senior lecturer at Harvard’s Graduate School of Education, said there is probably not a single cause to explain the data but rather interacting causes that vary by race, ethnicity, class, culture and access to mental health resources. In 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association together declared ‘a national state of emergency’ in children’s mental health. A year later, the organizations sounded the alarm again.” [Washington Post, 2/13/23]
Los Angeles Times: Black Californians Hit Hardest for Health Disparities. “More than half of Black Californians said there was a time in the last few years when they thought they would have received better healthcare if they had belonged to a different racial or ethnic group, according to a report released Thursday. By comparison, 27% of Latinos, 12% of Asian people and 4% of white people responded the same way, the report said. The report from the California Health Care Foundation, a nonprofit organization focused on health issues in the state, summarized results from a survey that asked more than 1,700 Californians about their views on health equity, health costs, health access, housing, their experience in the health system and more. The results come as lawmakers, health providers and public health agencies grapple with how to explain and curb longtime racial health inequities. Overall, 54% of Californians had experienced at least one negative provider interaction, including 64% of Californians with low incomes and 50% of those with higher incomes, according to the report. But even when controlling for geographic region, income, gender, language and age, Black Californians were twice as likely as white Californians to report any negative experiences with healthcare providers in recent years.
Pharmacy Times: Lower Income Communities Have Worse Cardiovascular Health Disparities. “Rural counties with a higher percentage of Black residents have higher rates of heart disease, despite a general decline in heart disease between 2009 and 2018, according to a paper by researchers at the University of Georgia published in the Journal of the American Heart Association. Housing instability was an important factor that contributed to death from cardiovascular disease (CVD), as was food insecurity. This supports previous findings, which determined that having a low income can create stress that leads to inflammation and illness, thus providing an explanation as to why socioeconomic status can increase risk of death from CVD. In the current study, investigators collected data from this Department of Health survey. What they discovered is that counties with a higher incidence of CVD had a larger number of residents lived in mobile homes. Conversely, counties with higher household income and access to quality health insurance (Medicare) had lower rates of death from CVD. [Zhou] Chen explained that increasing food stamp availability could help address high rates of CVD in certain communities, although affordable housing and health care require more government action.” [Pharmacy Times, 2/23/23]
AP: Native Americans Are Facing Even More Barriers to Access Abortion Services Post-Roe. “Getting an abortion has long been extremely difficult for Native Americans….It has become even tougher since the Supreme Court overturned Roe v. Wade. New, restrictive state laws add to existing hurdles: a decades-old ban on most abortions at clinics and hospitals run by the federal Indian Health Service, fewer nearby health centers offering abortions, vast rural expanses for many to travel, and poverty afflicting more than a quarter of the Native population. Among the six states with the highest proportion of Native American and Alaska Native residents, four – South Dakota, Oklahoma, Montana and North Dakota – have moved or are poised to further restrict abortion. South Dakota and Oklahoma ban it with few exceptions. In some communities, the distance to the nearest abortion provider has increased by hundreds of miles, said Lauren van Schilfgaarde, a member of Cochiti Pueblo in New Mexico who directs the tribal legal development clinic at the University of California-Los Angeles. Many advocates worry that reduced abortion access will make things even worse for women already facing maternal death rates twice as high as their white peers, teen birth rates more than twice as high as whites, and the worst rates of sexual violence.” [AP, 2/14/23]
New York Times: Rural Hospitals Are Closing Their Maternity Units. “Astria Toppenish Hospital is one of a string of providers across the nation that have stopped providing labor and delivery care in an effort to control costs — even as maternal deaths increase at alarming rates in the United States, and as more women develop complications that can be life-threatening. From 2015 to 2019, there were at least 89 obstetric unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetrics care, according to the American Hospital Association. In the past year, the closures appear to have accelerated, as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined. A study of hospital administrators carried out before the pandemic found that 20 percent of them said they did not expect to be providing labor and delivery services in five years’ time. Women in rural areas face a higher risk of pregnancy-related complications, according to a study by the Commonwealth Fund. Those living in so-called maternity care deserts are three times as likely to die during pregnancy and the critical year afterward as those who are closer to care, according to a study of mothers in Louisiana. The United States is already the most dangerous developed country in the world for women to give birth, with a maternal mortality rate of 23.8 per 100,000 live births — or more than one death for every 5,000 live deliveries. Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying of pregnancy-related complications is three times as high as that of white women. Their babies are almost twice as likely to die during the first year of life as white babies. Women of color are more likely to live in maternity care deserts or in communities with limited access to care. According to the March of Dimes, the maternal health nonprofit, seven million women of childbearing age reside in counties where there is no hospital-based obstetric care, no birthing center, no obstetrician-gynecologist and no certified nurse midwife, or where those services are at least a 30-minute drive away.” [New York Times, 2/26/23]
New York Times: Maternal Mortality Rates Have Stopped Falling Globally for the First Time. “Although maternal mortality rates declined worldwide from 2000 to 2020, almost 800 women still die of pregnancy-related complications every day, according to a grim report issued Wednesday by the World Health Organization and other agencies of the United Nations. Despite early improvements in maternal health during the 20-year period, progress has stalled in many regions, and in recent years maternal mortality rates have risen sharply in Latin America, the Caribbean and, perhaps surprisingly, in Europe and North America. In the United States, maternal deaths rose sharply during the pandemic. In 2021, hundreds of deaths resulted from pregnancy complications exacerbated by Covid infections, according to data from the U.S. Government Accountability Office. Among wealthy industrialized nations, the United States has the highest maternal mortality rate. According to the W.H.O., the rate almost doubled between 2000 and 2020, rising to 21 deaths per 100,000 live births in 2020, or one in 5,000, up from 12 deaths per 100,000 births in 2000, or 1 in 10,000. According to the Centers for Disease Control and Prevention, whose own figures put the U.S. maternal mortality rate for 2020 at 23.8 per 100,000, the risk is almost three times higher for Black women, at 55.3 per 100,000, than for white women, whose mortality rate is 19.1 per 100,000. Native American women also face a much higher risk of dying during and after pregnancy, compared with white women.” [New York Times, 2/22/23]