Transcript of interview with Interview with J. Nadine Gracia, MD, MSCE, deputy assistant secretary for minority health and director of the Office of Minority Health at the Department of Health and Human Services
Interview conducted by Natalie McGill, reporter for The Nation’s Health newspaper.
Listen to this interview as a recording on our podcast page.
The Heckler Report, which turns 30 this month, is a landmark report that outlines the health and equity and disparities among minority populations in the U.S. Since then, there's been progress in areas such as childhood vaccinations, life expectancy, and obesity, but there are still challenges that exist today. If the Heckler Report was written today instead of 1985, what are some key points you would want to highlight to be addressed in the next 30 years?
It's important to note that when Secretary Heckler formed the Task Force on Black and Minority Health, it was an unprecedented action for the U.S. government to convene a group of health experts to conduct a comprehensive study of the health status of racial and ethnic minority populations. And among its findings, the report of the Secretary's Task Force on Black and Minority Health, which is commonly referred to as the Heckler Report, highlighted the significant disparities that exist among racial and ethnic minorities, showed that approximately 60,000 excess deaths occurred among minorities each year. In fact, Heckler called these disparities an affront to both our ideals and to the ongoing genius of American medicine.
You're right, we've seen important progress over the years. Cancer deaths among blacks have decreased; obesity rates among low-income preschoolers have declined for the first time in three decades; and the disparities in childhood vaccination rates among children of color and whites are nearly nonexistent. However, despite the progress that we've made, the health of minorities still lags behind the U.S. population as a whole on many fronts. For example, cancer deaths have decreased among blacks overall. But black women still die from breast cancer at much higher rates than white women, and black men are two and a half times as likely to die from prostate cancer as white men.
So while the death rate, for example, among racial and ethnic minorities has decreased since 1985, people of color still face that grim reality of dying due to a preventable illness in higher numbers than whites.
So closing this gap and achieving health equity have to be the focus for our future work and for future generations. To do so, requires a comprehensive approach. That includes reducing disparities in access to care; improving quality of care; enhancing the diversity and cultural competency of the workforce; investing in community-level population health programs that promote health and wellness; furthering our research in health disparities; and the quality and availability of data to identify disparities to track our progress and to tailor our interventions accordingly.
Affordable Care Act reform has sought to reduce the health disparities outlined decades ago in the Heckler Report, particularly when it comes to equitable access to insurance and preventive care services. What successes have you seen in building awareness among minority populations about health care access, and what challenges are there to making sure people who have insurance continue to have it?
The Affordable Care Act is providing millions of Americans with access to quality affordable health coverage, including communities of color. Over 16.4 million uninsured people have gained health insurance coverage, and some of the biggest gains have come among racial and ethnic minorities. Among African-Americans, the uninsured rate declined by 9.2 percentage points, resulting in 2.3 million adults gaining coverage. And among Latinos, the uninsured rate dropped by 12.3 percentage points, resulting in 4.2 million adults gaining coverage.
It's also important to note that in 2015, nearly 80 percent of market place shoppers who used Healthcare.gov could purchase coverage for $100 or less after tax credits.
The Affordable Care Act is also promoting prevention. Of the 137 million people who have access to recommended preventive services, such as blood pressure screenings and immunizations without cost sharing, an estimated 15 million are black, 17 million are Latino, 8 million are Asian-American and 1 million are American-Indian. And we know that in-person assistance plays a vital role for people signing up for coverage, especially in minority communities. The National Healthcare Call Center also provided translation services in more than 150 languages.
Here at the Office of Minority Health, we also worked through our partnership to increase coverage in community initiative to increase enrollment among racial and ethnic minorities in the health insurance marketplace. It's a $3.2 million grant program that's funding 13 organizations who have done everything from organizing enrollment events, to engaging community and faith leaders, to helping those without insurance sign up for coverage.
Another crucial aspect of the Affordable Care Act is providing access to care, and that has provided $11 billion for nearly 1,300 community health centers, which are an important source of health care for minority and underserved communities. Nearly one out of every four patients at a health center is African-American; one in every three patients is Latino. Through these investments, we're increasing the number of patients through the community health centers by nearly five million.
One of our challenges certainly is making sure that people who now have coverage know how to use that coverage to get the primary care and preventive services that will help them and their families stay healthy. There's a new initiative called the Coverage-to-Care Campaign, which is a roadmap to help explain what health coverage is and how to use it to get the primary care and preventive services that can help families live healthy, productive lives. Coverage-to-Care has a user-friendly roadmap to better care and a healthier you and other health literacy materials that are available in eight languages. We've seen that nearly 870,000 roadmaps have been ordered, and 25,000 have been downloaded by organizations from all 50 states and Washington, D.C., including more than 97,000 in Spanish and more than 110,000 in other languages.
One of the keys to improving care for underserved populations is to tailor health care services so they are culturally appropriate. Your office sought to address this through initiatives such as the Center for Linguistic and Cultural Competency in Health Care and the National CLAS Standards. How have you seen initiatives like these improve the healthcare experience, and in what ways will this expand?
Well, we are becoming an increasingly more diverse nation. We've seen, for example, that the majority of infants born in the U.S. are now members of racial and ethnic minority groups; yet, too many Americans struggle to achieve good health because health care that is available to them doesn't adequately address their cultural and linguistic needs. And when we think about culture, culture includes deeply-held beliefs, customs and influences.
It's important to understand that culture is not only race and ethnicity and primary language, but also elements such as socio-economic status, disability status, whether one is from an urban community or a rural community, that our spirituality can impact and influence our perception of health. So to provide services that are respectful of and responsive to the individual cultural health beliefs and practices of preferred languages and health literacy levels and communication needs of patients is really critical in itself, and it's something that needs to be employed by all members of an organization at every point of contact.
The National Standards on Culturally and Linguistically Appropriate Services in Health Care, or also known as the National Class Standards, these standards seem to improve quality of care, advance health equity and reduce health care disparities by providing a framework for health and health care organizations to serve our nation's increasingly diverse communities. The cultural and linguistic competency initiatives, such as the National CLAS Standards, are an important part of efforts to reduce these gaps in healthcare access and quality.
Research and practice experience have shown that health care quality can be improved when care is provided in an environment that is respectful of and responsive to those cultural and linguistic needs of the patients who are being served. We've seen studies, for example, that have shown that when a trained interpreter is not used at admission and discharge, that it can increase length of stay in hospitals. We've seen studies where hospitals that have actually improved the culturally-appropriate services in the design of their maternity suite have seen an increase in the patient volume that they have in that hospital; therefore, increasing their market share.
These standards are really designed to help not only consumers, but also the providers in the health systems that serve communities to provide high quality services.
You were at the forefront of creating Health and Human Services Environmental Justice Strategy, which addresses the health and equity of low income and minority populations exposed to environmental hazards. With an increased national focus lately on how the environment affects health, how can we continue to address underserved communities adversely affected by environmental dangers?
In 2012, the Department of Health and Human Services published its Environmental Justice Strategy and Implementation Plan. This strategy provides direction for HHS efforts to achieve environmental justice as part of our mission by maintaining three guiding principles: First, creating and implementing meaningful public partnerships; second, to ensure inter-agency and intra-agency coordination; and third, to establish and implement accountability measures. The way in which we are implementing those principles are through four strategic elements: through policy development and dissemination; through education and training; through research and data collection; and analysis and utilization, as well as through services.
Some of our examples of our accomplishments to date have been in providing guidance to state and local health departments to help them prepare for the impacts of climate change. Through our programs, another accomplishment has been providing hazardous materials training to approximately 10,000 people in more than 30 communities across 20 states and D.C. through our worker training program since that program began in 1995. We're also doing important work to educate communities about their rights through technical assistance and services provided by the Office for Civil Rights to ensure that these communities are not disproportionately exposed to environmental hazards.
Lastly, your clinical background is in pediatrics epidemiology, which has given you one-on-one experience in working with children from underserved areas. How has your work as a physician influenced your approach to creating national public health interventions affecting U.S. racial and ethnic minority populations?
Well, in my clinical practice, I served predominantly children and youth who were from disadvantaged communities. One of the things that I observed quickly in my practice was how important these broader social determinants of health really impact the health and wellbeing of the children in the families that I served. You're caring for poor families who are struggling to make ends meet or a child who doesn't have access to high quality education, parents who are concerned about their children going out to play in their neighborhood because of concerns of the safety in their neighborhood; the mother who has to make the decision between paying the bills and buying medications, or taking her child to medical visits. It gives you a broader perspective on some of the challenges that our families, and certainly these children, face.
Part of my training as a pediatrician was to do home visits to patients in my practice, and it was an eye-opening experience to be able to go to their homes and see the communities that they lived in. To see where, in many cases, they lacked access to transportation that would be able to get them to the various places that they needed to go. To see the types of neighborhoods that they lived in where there might not be safe places for the kids to play, and where the cost of getting healthy foods was certainly a challenge. That provides a great deal of perspective and influences me as I considered and worked and developing programs and policies to benefit those communities, to take those stories and those children into account and their families when designing policies to ensure that there is equity, that they have opportunities. And where there is not opportunity, that we look to ways and working not just within health care, but also with other sectors to be able to provide opportunities so that they can truly reach their full potential for health.
Well, Dr. Gracia, thank you so much for taking the time to talk. I really appreciate it.
Well, thank you. It has been a pleasure, Natalie, and I'm really thrilled that you're doing this piece.