01.11.10

Talking Equity: An Interview with Brian Smedley

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Brian Smedley is vice president and director of the Health Policy Institute at the Joint Center for Political and Economic Studies. The O’Neill Institute’s Lester Feder spoke with him about health reform and disparities in health-care access.

Lester Feder: I wanted to start by asking you what you generally think of the health reform legislation it looks like Congress is going to pass, and particularly, in regard to how it’s going to reduce disparities in care.

Brian Smedley: As you know, we have analyzed both the House and Senate legislation, which we’ve published at www.jointcenter.org/hpi. Obviously, any effort to expand access to affordable health insurance is going to disproportionately help racial and ethnic minorities, because people of color constitute about half of the 46 million uninsured Americans.

Both the House and the Senate bills, however, will not achieve universal insurance coverage, which of course many policy analysts and researchers believe will be important to help contain costs and to insure that people have access to timely, high-quality care. One estimate is that there will still be approximately 23 million Americans left uninsured as a result of the Senate bill and another 18 million uninsured if the House bill is enacted. 


There are provisions in both bills, however, that we think will be very constructive and helpful toward addressing both access to health care as well as addressing gaps in the quality of care. These include efforts to strengthen the health-care safety net, because even with more people covered with insurance there’s still going to be a need for safety-net institutions. Clearly any effort to expand community health centers—as both the House and Senate bills do—will be very helpful to improve access to care for both low income people and people of color.

Both the House and the Senate bills also have provisions to stimulate the health-care workforce, and in particular to stimulate and increase its diversity. There’s evidence showing that racial and ethnic minority doctors, nurses, dentists and others are more likely to want to serve underserved communities. It’s also true that greater diversity in the health-care workforce can help address cultural and linguistic barriers.

Both bills also call for better data collection and monitoring of health-care access and quality disaggregated by patients’ race, ethnicity and primary language.

Another positive element is that both bills increase the federal investment in prevention to help people avoid getting sick in the first place. Both establish prevention trust funds and the House bill even goes so far as to establish health empowerment zones, which is a notion that greater investments in improving community conditions for health can help people be healthier in the first place.

Lester Feder: Are you talking about environmental health? Are you talking about health education?

Brian Smedley: There is a growing body of literature showing that where one lives is an important and powerful predictor of health status. Some argue that your zip code is more important a predictor of your health status than your genetic code.

Some communities lack access to healthy foods—they may lack access to grocery stores and may have an abundance of fast food stores, liquor stores, tobacco vendors. Community health empowerment zones would stimulate investment in establishing grocery stores in communities that lack them. We also know that environmental health threats—air, water, and soil pollution—are more abundant in low-income communities and communities of color. Investing in cleaning up and reducing pollution in these communities can go a long way toward helping people be healthier. In communities that lack parks or recreation facilities, we can do more to encourage people to exercise or lead active lifestyles by establishing safe places for people to play and exercise.

Lester Feder: When you look ahead towards the merging of these two bills, what are the things that concern you the most?

Brian Smedley: When we look at the demographic changes coming in this country, by 2042, about half of the people living in the United States will be people of color, so it is important to make equity a key goal of any health reform legislation. Obviously, the House bill attempts to expand insurance coverage to a much broader segment of the population. The best of both bills to achieve equity would be important to retain in conference.

Lester Feder: Do we know the demographic makeup of those likely to be left uninsured?

Brian Smedley:
It’s safe to say that, given the fact that about half of the currently uninsured are people of color, at least half or more of the future uninsured are likely to be people of color. This includes immigrants—including some legal immigrants—if the five-year bar on the waiting period to receive Medicaid is not lifted. And of course the 11 or 12 million folks who are here without documentation would not be eligible for coverage under either the House or the Senate plan.

Lester Feder: Do you view the debate around abortion coverage as also being a question of equity for low-income women?

Brian Smedley: Yes. It’s important that all women—and particularly, women who might not otherwise have access to safe reproductive health services such as low income women and women of color—be able to have access to comprehensive reproductive health services. Any effort to restrict access to reproductive health services is going to be ultimately harmful to the health of women of reproductive age as well as their children.

Lester Feder: Overall when you look at the debate around health reform, do you think that questions of equity have gotten enough discussion?

Brian Smedley:
I do not. I think that equity has been, at best, tangential to the discussion, which has been unfortunate because we really can’t achieve our goals of expanding coverage and reducing costs and improving quality unless equity is a key consideration in the legislation.

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