Eliminating African-American Health Disparity via History-based Policy
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Recommendations of the AAHI

Close the gap for the uninsured and underinsured

Lack of health insurance inhibits healthcare access and contributes to the poor health status of African-Americans. To bring African-Americans to parity with their insured counterparts, the AAHI recommends:

1. Expanding Medicaid eligibility.
2. Expanding state children's health insurance programs (SCHIPs) like Michigan's Mi-Child Program to working adults.
3. Funding initiatives to increase enrollment of eligible populations into safety net and community healthcare programs already in place.
4. Reallocating the use of tobacco settlement dollars for health education, primary healthcare and specialty healthcare programs and initiatives.
5. Facilitating a collaboration of healthcare providers, hospital systems, federally qualified health centers (FQHCs), local health departments, school systems and faith-based communities to develop and deliver preventative and clinical health programs.
6. Increasing disproportionate share hospital (DSH) funding to urban and rural hospitals.
7. Continuing to advocate for timely payment of private healthcare insurance claims.

Improve health and dental care options

While "access to health care" and "lack of healthcare insurance" are closely connected, other factors influence access to care. Under-funding in the Medicaid and federal Medicare programs has created both a severe revenue shortfall in urban hospitals, and urban hospital and free clinic closures, phenomena that particularly affect at-risk and disenfranchised patients. There is also considerable concern that Medicaid fee-for-services programs do not offer reimbursements to dentists for providing primary dental care services. To improve the healthcare and dental options for African-American patients, the AAHI recommends:

1. Providing tax breaks to physicians as an incentive for them to practice in federally-mandated health professional shortage areas (HPSAs) and in medically under-served areas and populations (MUA/MUPs).
2. Forgiving loans of medical students who commit to work in HPSAs orMUA/MUPs upon graduation from medical school.
3. Increasing the ceiling of Medicaid poverty guidelines.
4. Changing public providers' and policymakers' perceptions of oral health and disease so that oral health becomes an accepted component of general health, and subsequently building an infrastructure that meets dental needs.

Improve mental health care

Mental illness in its various forms is a health issue that has not been vigorously examined in the Black community. The 2000 Surgeon General's Report on Mental Health revealed that mental illness is as prevalent among racial and ethnic minorities as in white populations, but is treated in a system that has little information about the cultural context in which these illnesses affect African-Americans and their treatments. Thus, the AAHI recommends:

1. Increasing the level and scope of mental health research in the African-American community, and ensuring that such research addresses the myriad socioeconomic, age, developmental, gender and geographic issues that arise.
2. Integrating culturally-competent services that incorporate understanding history, traditions, beliefs and value systems of African-Americans into mental health assessment, diagnosis and treatment methodologies.
3. Holding mass media, entertainment and other popular culture vehicles accountable for perpetuating negative images and stereotypes of African-Americans, particularly for youth.
4. Collaborating with entities dedicated to eradicating racism and educating how racism and cultural insensitivity erodes the individual and group self-esteem of numerous African-Americans.

Ensure fair data collection, research and reporting

Racial and ethnic disparities in health status, access to care and quality of care have been studied across myriad clinical areas. However, current quality assessment tools used by health plans, employers and state and national accreditation entities of hospitals and public health systems do not, for the most part, conduct "cultural quality" assessments of patient care by race and ethnicity, rendering it difficult to study health disparities and the success of efforts created to eliminate them. Thus, the AAHI recommends:

1. That staff resources and technical assistance be provided for epidemiological surveillance, along with database development to monitor the health status objectives of African-Americans in each state.
2. That performance measures used by states to contract with healthcare plans be stratified by race and ethnicity.
3. That all agencies receiving state funding for the provision of health services be mandated to collect quality assessment data by race and ethnicity of patients served.
4. That it be a violation of state law to use any racial and ethnic data collected for surveillance or research purposes to discriminate against individuals regarding their health access or insurance coverage.
5. That providers lobby the Joint Commission on Accreditation of Healthcare Organization (JACHO) and the National Council on Quality Assurance (NCQA) to measure the quality of health based on race and ethnicity.

Improve service delivery

Various socioeconomic, cultural, historical, attitudinal (both physician and patient-based) and racial factors contribute to disparities in service delivery standards experienced by the African-American community. A critical factor is the fact many African-Americans have a deeply-ingrained historical mistrust of American medicine, its infrastructures and professionals, and particularly its physicians. Thus, the AAHI recommends:

1. Mandating interdisciplinary cultural competency/cultural sensitivity training for health practitioners at the undergraduate, graduate and post-graduate/continuing education levels, and establishing standards for them.
2. Maximizing the use of a best practices program or strategies that use screening and treatment modalities tailored to African-Americans.
3. Stimulating interest, mentoring and retention of blacks in healthcare training programs at all levels and in all disciplines as early as the elementary school level, and demanding accountability measures in these programs.
4. Encouraging the use of interdisciplinary training to educate health professionals about race, ethnicity, culture, and the historical African-American medical and health experience using biomedical ethics, medical narrative, history of medicine, medicine and the arts, literature and medicine, medical anthropology, and medical sociology curricula.

Enhance community outreach

Because of advances in medical research, intricate technical information and new paradigms of illness, disease and treatment processes must be translated to the black patient in an empowering, culturally-relevant and user-friendly manner. Thus, the AAHI recommends:

1. Using culturally and linguistically-appropriate health education materials to convey critical health information when possible.
2. Developing "one-stop shopping" health center models within the community to provide neighborhood-based and culturally-sensitive care and advocacy services.
3. Reconfiguring school-based health education, health promotion and disease prevention curricula to be more culturally-sensitive and empowering for African-American students.
4. Developing a statewide advocacy network of citizens, perhaps via e-mail or fax, in the manner of the daily Kaiser Health Policy Report to share information regarding African-American health issues.

Advocate environmental justice

Blacks are at particularly high risk for health concerns like lead poisoning or environmental toxin exposure, because environmental hazards often present in and near urban centers, and near deteriorating neighborhood infrastructures, brown-fields, landfills, polluted water sources or underground storage tanks and waste management sites. Thus, to ameliorate what is now called "incidences of environmental racism," the AAHI recommends:

1. Raising awareness levels in the black community and the health-and-human-service professions regarding environmental racism issues.
2. Creating opportunities for brownfield redevelopment for African-American citizens and vendors, or preventing future brownfields.
3. Commissioning a Geographic Information Systems (GIS) study to identify areas in and around black neighborhoods where environmental injustices/inequities exist.

Promote healthy lifestyle changes

Studies reveal that among the four determinants of disease (behavior/lifestyle, genetic constitution, environmental exposure and medical care), behavior and lifestyle constitutes the largest contribution to disease (48%). An informed and proactive approach to preventing disease is of vital importance to African-Americans, a group which has been at higher risk for dangers like cardiovascular disease, cancer, stroke, diabetes, gall stones, prostate cancer, uterine fibroids, obesity and traffic crashes. To help this populace pursue optimal health via modifying behavior and lifestyle choices, the AAHI recommends:

1. Encouraging low-fat, high-complex carbohydrate diets that contain national nutrition standards for consuming vegetables and fruits.
2. Encouraging health practitioner-approved regular exercise and fitness regimens.
3. Promoting awareness of key government programs like the Health Research and Service Administration program which provides free medication to HIV/AIDS patients whose income level is below 300% of the poverty level.
4. Mandating HIV/AIDS testing of persons entering and exiting any state correction facilities, and assuring them treatment.

Conclusion

These recommendations, while controversial, are necessary vortices of dialogue to change 21st-century American medical culture. The healthcare system must appreciate the diverse population it serves by remembering its historical roots and working to destroy the lingering effects of racism. Medicine must help its patients become empowered health consumers while reexamining core issues of race and racism. The time has come for the social forces that have negatively influenced American medicine to heal and transform American society, a process that requires African-American targeted health policies.

Karen Williams can be reached at Kwilliam@co.wayne.mi.us.
Veronica W. Johnson can be reached at Veronicj@umich.edu.

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