Less money for health, more for preschool

By Katie Kerwin McCrimmon

Spend less on health care and much more on preschool.

Thats the prescription that an international expert on health disparities gave Thursday in Denver to help reverse inequities that leave low-income racial and ethnic minorities much sicker and facing shorter life expectancies than wealthier whites.

Health care should get less (funding) and education should get more, said Dr. Paula Braveman. Early childhood development should get the lions share. Having a strong social safety net would make health indicators look a lot better.

Braveman is director of the Center on Social Disparities in Health at the University of California, San Francisco School of Medicine. She spoke at an event that The Colorado Trust hosted called From Health Disparities to Health Equity.

A new report from The Trust has found that racial and ethnic minorities make up more than 346,000 of Colorados 829,000 uninsured people. Not only are minorities less likely than the general public to have insurance and access to health care, but they also suffer worse health outcomes, the report found.

One of the greatest frustrations about health disparities, said Braveman, is that they seem to persist despite some well-intended policies to reverse them.

For instance, she said that babies born to African American moms are two or more times as likely as white babies to be born too small. Low birth weight is closely linked with infant mortality, childhood disability and chronic disease in adulthood.

In the 1980s and 90s, Braveman said there was great hope that expansions of Medicaid would bring better medical care to African American moms and in turn, lead to better outcomes for their babies.

Expansions of Medicaid coverage dramatically narrowed the gap between African American and white women but did nothing to narrow the disparities in babies health, Braveman said.

She said one of the only health programs that seems to work is called CenteringPregnancy.Developed by a nurse-midwife in Connecticut, the program brings pregnant moms together for group visits throughout their prenatal care. The model is being used at community health centers in Colorado where the mothers often keep meeting long after their babies are born and offer positive role models and support to each other. Both the mothers and babies do better.

Aside from group maternity care, the greatest hope seems to lie in education. Braveman said study after study has shown that high quality Head Start programs change lives. Shed like to see the much-praised Harlem Childrens Zone in New York used as a model throughout the U.S. The program provides every kind of service a family could need to help children within a 100-block area of Harlem succeed from birth through college. In order to reverse disparities there, HCZ workers address everything from crumbling apartments to failing schools to violent crime and chronic health problems.

Braveman said reversing health disparities is as fundamental as protecting human rights.

Weve got an obligation to focus on those with the greatest obstacles, she said. Disparities are health differences that are closely linked with social or economic disadvantage.

T.R. Reid, a journalist and author who made the PBS documentary, Sick Around the World, led a discussion with Braveman and asked how the wealthiest country in the world stacks up with other countries when it comes to health disparities.

We rank at the bottom among affluent countries, Braveman said. She referred to a Jan. 9 reportthat she helped author from the Institute of Medicine that found that Americans die at younger ages than people in almost all other high-income countries.

This health disadvantage prevails even though the U.S. spends far more per person on heath care than any other nation, the report authors found.

Braveman said the newest hypothesis among scientists is that chronic stress that African Americans experience from birth on regardless of whether they are born to poor or fairly wealthy families takes a toll on health.

Theres reason to believe that people carry around with them this awareness, this vigilance, Braveman said.

Chronic stress could bring lousy health. She said racial and ethnic disparities are relatively small among poor women. But, college-educated black woman fare much worse than college-educated white women.

Everybodys looking for the magic bullet, Braveman said.

When she looks at health around the world, she said the one potential answer is that most other countries provide universal preschool.

Its very disturbing that we still dont have universally high-quality Head Start types of programs. Its been effective for kids of all social classes, but particularly for kids (from low-income families).

Readiness to learn leads to lower incarceration, higher employment and lower poverty. We know those will in turn lead to better health. The science is there. We dont need any more studies to show that this works.

Braveman also said the new trend of Health Impact Assessments that view development and urban planning through the prism of health is also promising. (Click here to read about a public housing project that uses health metrics for every decision managers are making.)

In Colorado, providers at community health centers say they have the best luck in reversing disparities when they make it easier for patients to get health care.

Jessica Sanchez is chief quality officer for the Colorado Community Health Network, which serves more than 600,000 people through 17 health systems around the state. Sanchez is also a nurse practitioner at Denver Healths Park Hill Clinic.

She said offering flexible hours including evening and weekend appointments is working well. Group visits and help with both transportation and child care also are very attractive to patients. She said several of Colorados community clinics including Clinica Family Health Services, Salud Family Health Centers and Valley-Wide Health Systems in the San Luis Valley are experimenting with methods to reduce health disparities.

The other great thing they are doing is putting together patient advisory groups. They want their patients to be more active and involved in their health care decisions, Sanchez said.

Better feedback from patients helps clinics provide better services.

Everyday challenges that patients face, from taking care of children to having to take three buses to get to a clinic can have profound affects on a patients health, Sanchez said.

Providers and health managers also need to be realistic and accept incremental improvement. For instance, Sanchez said her patients often refuse to take their medications. The reasons can be complex. Perhaps they cant afford it or cant read the instructions. She had one patient who wasnt remembering to take blood pressure medication and also wouldnt quit smoking. Sanchez decided to tackle the first problem first. So, she helped the woman tape her medication to her cigarette pack.

It worked for her. Its not perfect. Then you work on the cigarettes when shes ready. The big success was getting her to take her medication.

A January study published in the Journal of Ambulatory Care found that Community Health Centers reported lower disparities for racial and ethnic minorities on various quality measures compared to national rates.

This study shows that the efforts invested by health centers to deliver the highest quality care in culturally appropriate ways works to help lessen health disparities and helps people of all racial and ethnic identities to become empowered to manage their own health care, Sanchez said.