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Monday, March 5, 2012

How Social Insurance Programs Can Reduce Health Disparities: Reflections from NASI’s 2012 Conference

Liz Lamoste

I was very excited to see NASI dedicate time to health disparities and determinants of health at this year’s conference, Social Insurance in a Market Economy: Obstacles and Opportunities, because it is important to have more conversations about how social insurance programs can help reduce health disparities.

While there are several definitions for health disparities, the concept basically refers to the following: “if a health outcome is seen in a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.” Determinants of health, a related concept, refers to“the range of personal, social, economic, and environmental factors that influence health status.”

To put these concepts in perspective,  the National Healthcare Disparities Report, published by the Agency for Healthcare Research and Quality (AHRQ), found that while quality is improving, access and disparities are not improving.  As of 2010, fewer than 20% of the disparities minorities and low-income people face showed improvement.

I first learned about these concepts in college when I volunteered with a nonprofit called Health Leads. This organization wanted to show students how poverty and poor health were connected, and did so by having college students volunteer as caseworkers in low-income and urban hospitals and clinics. I worked in Harlem Hospital’s Pediatric Ambulatory Clinic for two years.

Here is an example of a very common case: A child would frequently come into the clinic with pretty severe bouts of asthma, and the physician would prescribe whatever medication was necessary. That physician would then refer the child to me because she suspected that there was something in the child’s environment that was making the asthma systems worse despite medical treatment. After talking to the child’s parents, I would find that there was something in the child’s home, such as mold, that could be aggravating the asthma. I would then help that child’s family call the city to file a complaint and get their landlord to remove the mold, albeit with varying success.

My experiences with Health Leads showed me how different types of health disparities play out in real life, and how poverty can generate needlessly poor health outcomes. I became committed to working towards eliminating health disparities, and that I had, and still have, a lot to learn in order to understand these issues and figure out what actions are best to take.

Brian Smedley, of the Joint Center for Political and Economic Studies, brought these issues to light in his NASI conference presentation, Building Stronger Communities for Better Health: Moving from Science to Policy and Practice. He explained that the Joint Center had calculated the economic burden of health inequalities, and found that between 2003 and 2006, the combined costs of premature death and inequalities amounted to $1.24 trillion. He argued that racial segregation worsens health disparities by concentrating poverty and limiting  socio-economic opportunity. Smedley also provided the audience with a list of recommendations for addressing racial and ethnic health disparities, such as improving the education system, expanding “place-based” opportunities, and strengthening environmental and land use regulation.

In addition to the Joint Center, several other organizations and government agencies have started to tackle health disparities with strategies that recognize the importance of the different types of determinants of health. Examples include the Department of Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities and Healthy People 2020.These initiatives focus on identifying the different factors that contribute to or can help eliminate health disparities and developing plans for taking coordinated action around those factors.

For me, NASI’s conference emphasized that social insurance can and should be featured more prominently in the conversations to end health disparities. Likewise, health disparities and social determinants of health should continue to be included in conversations that focus on how to strengthen social insurance programs. Medicaid and Medicare, for example, arguably have the most obvious connection to health disparities. Lawrence P. Casalino wrote on Medicare’s ability to help eliminate racial and ethnic health disparities in a NASI 2006 brief and working paper, which focused on using Medicare as a tool to push for quality improvement. He also pointed out that indiscriminately focusing on quality improvement could make health disparities larger if quality efforts did more to improve health outcomes for whites than for people of color, but did not foreclose the possibility that quality improvement initiatives may be able to help reduce health disparities.

In a 2007 Center for Health Care Strategies toolkit, the authors focused on Medicaid’s potential to reduce racial and ethnic health disparities through quality improvement in managed care. The toolkit focused largely on how plans could “use data to identify and stratify health care disparities, develop patient-centered approaches to care, and collaborate with key stakeholders to reduce disparities.”

The role of social insurance in reducing and eliminating health disparities is not limited to these health programs. For example, Meizhu Lui focused her conference presentation on how to make Social Security more accessible to communities of color, especially as poverty among the elderly is higher in African-American and Latino communities than it is for whites. It may be that Social Security and other social insurance programs can do the most help to reduce health disparities through reducing poverty.


Liz Lamoste is a second-year student at the University of Michigan Law School. She is currently a board member of the Michigan Universal Health Care Access Network (MichUHCAN), co-coordinator of the Food Stamp Advocacy Project, and President of the Michigan Health Law Organization. Liz was one of six students and young professionals awarded a scholarship to attend NASI’s 24th annual policy research conference January 26-27, 2012, in Washington, DC.

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