States play a role in eliminating health disparities

While federal efforts are under way to reduce racial and ethnic health disparities, states also have a significant role to play, governors, legislatures, and agencies may not know where or how to start. Researchers from Harvard University, under contract to the Commonwealth Fund, have produced a state policy agenda that gives policy-makers a menu of interventions that have been implemented in various states to address disparities in minority health and health care.

Harvard School of Public Health professor Brian Gibbs, who directs the Program to Eliminate Health Disparities in the Division of Public Health Practice there, tells State Health Watch that health disparities have not been at the forefront of policy-maker concern, and it is important to understand the significant differences in which groups fare better in terms of reduction in death rates for some diseases and improvement in quality of life. He says a recent report from the Institute of Medicine looked at a deeper level to help appreciate the disparities in health care, and says there has been more scrutiny at the federal level than at the state level.

"The agenda we produced is one small effort to probe the gap in health care for states," Mr. Gibbs says. "It’s not necessarily a blueprint, but some suggestions on how policy-makers can frame an agenda for their state."

Janet Scott-Harris, one of the researchers who is a W.K. Kellogg Fellow in Health Policy Research at the Heller Graduate School of Brandeis University, says the authors want to give policy-makers different avenues with which to serve their constituents. "They can target disease-specific areas if they want, work force development, capacity, or infrastructure," she says.

The report noted that a national strategy to achieve a public health goal most often requires state involvement. While many states now sponsor specific health programs to help members of racial and ethnic minorities, health disparities as such have not been a high-level issue. Key programs cited in two areas of concern include:

State infrastructure and capacity. Efforts can include standards tailored to community needs for cultural and linguistic competency; data collection and analysis; support of home- and community-based services for the elderly; insurance coverage for the more than 50% of U.S. uninsured who belong to racial and ethnic minorities; primary care access through community health centers and other means; use of state purchasing power to require data collection and reporting; influencing professionals, institutions, and health plans through licensure and regulatory requirements; development of state infrastructure and resources; and work force development to increase the number of minority health care professionals.

Health conditions. Comprehensive state programs can address issues in asthma, cancer, cardiovascular disease, diabetes, HIV/AIDS, immunizations, infant mortality, injury prevention, mental health, obesity, physical activity, tobacco use, and oral health.

The authors say eight key needs arise for state policy-makers, and those who seek to develop omnibus or multifaceted legislation to address disparities would do well to ensure that any proposal addresses these needs:

1. Better and more consistent data collection. The report says major inadequacies in data collection hamper efforts within individual states and hinder efforts to understand differences among states. At the extreme, it says, some state surveillance systems still categorize all racial and ethnic groups as black or white only, rather than following the accepted national standard from the Office of Management and Budget for American Indian or Alaska Native; Asian; black or African American; Native Hawaiian or other Pacific Islander; white; and Hispanic or Latino. States should also collect and report health data on the racial and ethnic subgroups that reside there, and they should initiate strategies to identify gaps in available data for small population groups.

2. Effective program evaluation. While the researchers initially intended to collect best practices among state efforts, they say they abandoned that term for the more ambiguous "promising practices." Practices are identified as promising based on case studies and other reports, as well as recommendations by researchers, policy experts, and state officials. The authors say their inability to find best practices prompts the recommendation that researchers and public officials work together to evaluate effectiveness of disparities interventions and document and publicize those programs and policies that yield positive results.

3. Emphasis on stronger cultural and linguistic competence in all disparities reduction activities.

4. Work force development programs and improvement to the cultural competence of all health care professionals.

5. Health screening and access.

6. Establishment of designated office, commission, council, or advisory panel on minority health.

7. Involvement of all health system stakeholders.

8. Creation of a national coordinating body to promote continuing state-based activities to eliminate racial and ethnic health disparities.

Listing the eight key needs makes sense, they say, because policy-makers have so much disparity information coming to them that they trouble identifying a place to start.

According to Amanda Navarro, a doctor of public health student at the University of Texas, there has been a lot of talk about health disparities, but people often don’t know the statistics describing the magnitude of the problem. "Policy-makers are aware of public health problems in their communities," she tells State Health Watch. "This is a toolkit so they can look at specifics relating to the problems they see."

Mr. Gibbs says the researchers recognize that some readers might think there is too much information, while others might say it still is not specific enough. "We had to balance how to present a lot of information as cogently as possible and then give references for further research."

Providing resources for communities that are having dialogs on health disparities and don’t know where to start allow them to focus on promising practices through which they can accomplish measurable outcomes, Ms. Scott-Harris adds.

The authors recognize there are necessary limitations to their work. she says they didn’t bring in any social, economic, or political issues and don’t want states to lose that context. They also don’t want states to think that if they put a specific program in place it will solve their disparity problems, Ms. Scott-Harris says.

And there is concern because they were not able to devote much time in the report to historical aspects of how health disparities have persisted and the context of what has been done to date to try to overcome disparities. "The context is underlying as well as overarching," Mr. Gibbs says. "It extends to limited life chances that affect all groups, just in a different way."

Those who worked on the report are heartened that more than 30,000 copies have been downloaded, putting it among the top five documents in Commonwealth Fund publishing history. Discussions are under way on steps that could be taken to build on the report, recognizing that states often are looking for technical assistance as a follow-up. Interest has been expressed by the Centers for Disease Control and Prevention Reach 2010 program.

"The next steps will vary by state and where states find themselves," Mr. Gibbs says.

(To see the report, go to