Civil society has to create the solutions to racial and ethnic health disparities

Like my fellow contributors to Health Justice CT, I believe that racial and ethnic backgrounds have too much of an effect on health outcomes. Thedata in support of this belief is strong.

Where I may disagree with my fellow contributors and others who care about this issue is how the problem is best solved.

The best way to address racial and ethnic health disparities is through civil society, the institutions and relationships formed by the residents of Connecticut without the involvement of the state government.

Unfortunately, many medical charities have stopped using their money to directly help people.Instead, they use the money they raise to lobby the government. Success at this gamble can turn thousands of dollars into millions.

But I would argue this makes charities weaker. They lose direct contact with those they want to serve while mastering the lobbies of Congress and state houses. We know what these skills do to career politicians; imagine what they do to charities.

Recent experience in Connecticut follows a similar trajectory. Gov. Dannel Malloy appointed a former state legislator to work in his administration as a commissioner-level advocate for nonprofits who get funding from the state.

This is a sad confirmation that civil society in Connecticut has all but disappeared in favor of state government.  Even Connecticut’s hospitals, while organized as nonprofits independent of the government, orient themselves towards state funding. This has left hospitals with nowhere to turn when the state announced it would tax them earlier this year.

Without an active civil society, citizens of Connecticut are left with fewer advocates and less responsive services.

And a stronger civil society will only help state government. Increased social engagement leads to more political engagement.

When the public organically solves problems, the state has fewer to tackle. In some cases, non-government solutions and services will compete with state ones causing mutual improvement

The state of Connecticut can be most helpful in addressing racial and ethnic health disparities in the places where it is currently responsible for them. Medicaid is well-known for its poor outcomes and false promises.

Researchers have found Medicaid patients have the same health outcomes as the uninsured. Some studies have found Medicaid outcomes are even worse than outcomes for the uninsured.

Scott Gottlieb, a medical doctor and former advisor to the Center for Medicare & Medicaid Services, wrote about this evidence recently in a Wall Street Journal op-ed, “Medicaid Is Worse Than No Coverage at All.”

Gottlieb, currently an NYU professor and scholar at the American Enterprise Institute, notes that a 2010 study of nearly 1 million surgeries found uninsured patients were 25 percent less likely than Medicaid patients to die in the hospital – even after controlling for socioeconomic and cultural factors.

In Connecticut, blacks and Hispanics are on Medicaid at nearly three and four times the rate of whites, respectively, according to Kaiser State Health Facts. Research has show that racial and ethnic health disparities show up even within Medicaid.

Because of the overrepresentation of blacks and Hispanics within Medicaid, their poor outcomes relative to their white peers within the program and the overall bad outcomes for Medicaid patients, the best thing state government can do to alleviate racial and ethnic health disparities is make Medicaid better.

Warning: more expensive and better are not synonyms. There are many design improvements to Medicaid that would improve outcomes without increasing costs.

Governments also have a poor track record in dealing with race. In addition to the well-known history of segregation, there is the Tuskegee Syphilis Study, conducted by the U.S. Public Health Service, which denied black patients treatment or even knowledge of their diagnosis.

The practice of redlining – denying home loans based on the racial and ethnic makeup of neighborhoods – began in the Federal Housing Administration long before it was adopted by banks.

When I was a Health Leadership Fellow with the Connecticut Health Foundation I remember a conversation when I asked where the line is between caring for racial health disparities and racism.

For example, a doctor can say, “Blacks are less healthy,” with two different meanings. One meaning implies inferiority, the other disparity. This is dangerous ground for government to tread.

I trust the people of Connecticut, their churches, associations and nonprofits to answer these difficult questions. They let state government do it for them at their own risk.

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  • ADunlay

    TRUE racial and ethnic health disparities must be
    addressed by the public; but I have to disagree with the author’s sentiment in the
    preclusion of the government. Much of the existing disparities are due to
    systematic and structural racism. Racial and ethnic health disparities are
    complex issues and require all entities to work together.

  • Drew Weymouth

    Not sure what you mean by “civil society,” or what types of “medical charities” are referenced here to solely lobby the government. Advocacy organizations exist to educate the government on the needs of the community. It’s the nature of how our political systems work.

    • http://www.raisinghale.com/ Zachary Janowski

      Drew, thanks for your comment. Civil society is everything from the Elks club to churches to foundations (plus many more). Increasingly, organizations like the American Cancer Society and Parent Project Muscular Dystrophy are lobbying the government to increase government spending through NIH and other vehicles instead of directly raising money through voluntary contributions. I can’t blame them. Congress has taught them that raising some money and then hiring lobbyists can turn thousands into millions. However, I think this strategy weakens the charitable mission of these organizations and won’t pay off in the long run. I don’t have a problem with charities ‘educating’ government, but education shouldn’t come with a spending wishlist.

    • http://www.raisinghale.com/ Zachary Janowski

      Drew, thanks for your comment. Civil society is everything from the Elks
      club to churches to foundations (plus many more). Increasingly,
      organizations like the American Cancer Society and Parent Project Muscular Dystrophyare
      lobbying the government to increase government spending through NIH and
      other vehicles instead of directly raising money through voluntary
      contributions.

      I can’t blame them. Congress has taught them that raising some money and
      then hiring lobbyists can turn thousands into millions. However, I
      think this strategy weakens the charitable mission of these
      organizations and won’t pay off in the long run. I don’t have a problem
      with charities ‘educating’ government, but education shouldn’t come with
      a spending wishlist.

  • Yaritzastarr

    How should we go about addressing health disparities as a society? Stating that it’s a civil responsibility is not a solution nor is it helpful to state that the government botches things up more. It is evident with the recent debt ceiling negations and utter failure of the healthcare reform… The healthcare reform has cost tax payers millions and how many people did it really help? More and more companies are not even offering healthcare to their employees anymore because they cannot afford it. The healthcare reform didn’t go far enough. There should of been a reform on healthcare costs.

    • http://www.raisinghale.com/ Zachary Janowski

      Sorry you didn’t find my suggestions helpful. I believe relying on government to fix the problem leaves us where we are today, as you mention, with federal healthcare reform – disappointed. Government efforts to date have focused on the price we pay for healthcare instead of what it really costs. In the future I hope to post on the need to break the cartel held by doctors that limits the supply of healthcare. Limits on supply = cost increases.

    • http://www.raisinghale.com/ Zachary Janowski

      Sorry you didn’t find my suggestions helpful. I believe relying on
      government to fix the problem leaves us where we are today, as you
      mention, with federal healthcare reform – disappointed.

      Government
      efforts to date have focused on the price we pay for healthcare instead
      of what it really costs. In the future I hope to post on the need to
      break the cartel held by doctors that limits the supply of healthcare.
      Limits on supply = cost increases.

  • SKT

    This is a very important issue.  To be honest, I had never really thought about the racial differences in health care.  The socio-economic disparities are well publicized.  Thank you for writing about this important topic.  I agree with ADunlay that health care disparities are complex and many organizations must work together to close the racial disparities.

  • Mfs47

    Dr. Gottlieb brings up some good points about Medicaid payments but to say that “Medicaid is worse than no coverage at all” is a leap of logic that  he did nothing to vallidate in his article. There are great flaws in the Medicaid system but who is paying for services is not the issue, it is how services are delivered and outcomes measured. Most of health care dollars are spent on chronic disease management and the poor suffer from complex chronic disease in numbers much larger than those who can afford health care. Right now evidence based health care does not exist on a level necessary for understanding systems issues, but it will in the not so distant future.

    Civil societies are a grand idea but show me where it is working. Who will develop this civil society? Who will lead it? and who will sustain it?  The belief that “civil societies” will emerge when the government stops funding health care is part of a “let them eat cake” world view that comes when the gap between the rich and the poor widens. The willingness to take down the safetynet is usually proposed by those who never walked a tightrope.

    Yesterday I took care of a woman who has not been able to get health care for herself for more than 5 years because she is unemployed and spending 24 hours a day taking care of her husband who cannot walk or feed himself because of a stroke. She has diabetes and hypertension. What ” civil societyt” should I refer her to? Will they provide her with medications over a long period of time? Will they translate for her when she goes to the doctor? Will they find someone to take care of her husband when she goes to the doctor?
    The cost of coordinating “civil” resources are extraodinary.

    Our current system is deeply flawed but it emerged in response to the deficits of a civil society. If you want to tackle systems problems you must address the fact that they occur in government funded endeavors and those of “civil societies”.  And how do you address health equity and health justice in a “civil society”? How do you say who gets the compassion and generousity of a “civil society” and who gets left on the street.

    • Anonymous

      There are many sad stories like the one you shared in your comment. Unfortunately, billions in government spending haven’t done anything to help this woman either. Unless you are a state or federal worker, your assistance was part of civil society. I agree that there are many deficiencies in civil society. I think that looking to the government first for solutions has caused some of those shortfalls. -Zach

  • http://twitter.com/biosophist Chike Brandon

    I really appreciate this argument.

    My only problem is at the bird’s-eye level (and not really in the details): civic society focused/initiated/managed and government-focused/initiated/managed programs are not always mutually exclusive, and I don’t believe that they are in the context of health justice.

    Allow me to explain.

    It is the fundamental job of government to execute the will of the people based on our collective belief in rights, virtues, morals, and principles, all crystallized into doctrines, laws, and policies. This goes for small government or big government.

    This includes defining, and protecting, those items which qualify as rights for all.  Insofar as there are health injustices that we fundamentally believe violate these rights, it is, arguably, our duty as citizens to advocate for government to respond. This is no different than how we campaign and lobby for other government actions and initiatives to help thwart threats to our general-well being and rights (natural disasters, military threats, epidemics, etc).

    Everything else — boutique issues, niche issues, issues that affect small population subsets, etc, are absolutely the domain of civic society, and should remain that way.

    Let’s use a hypothetical to illustrate why I agree with you:

    If a random balding condition affects African-Americans from southwest New Haven for a random reason (say, some odd combination of alleles), and this community wants to address this “health disparity,” its well within anyone’s right to suggest that because the issue is relatively small, affects only a small subset of people and isn’t the product of structural violence, then absolutely — they should not lobby government to address it, and that yes, they should utilize their own resources (civic society) to solve it.

    The above hypothetical is actually realistic; it describes a host of niche illnesses and issues.  The problem with the above is that it *doesn’t* address many others, and I’d argue that these “many others” constitute the bulk of the concerns of the health justice movement:

    a) Diabetes and other non-communicable diseases, as the product of the corporate welfare systems and conflicts of interests:

    http://epianalysis.wordpress.com/2011/04/19/ncds/
    http://www.washingtonpost.com/wp-dyn/content/article/2010/10/21/AR2010102106900.html

    b) Environmental racism — toxic dumps, power plants, other technologies which contaminate air and water supply, disproportionately placed in some communities relative to others, and these trends defying any normal explanation:

    http://www.sciencedaily.com/releases/2007/07/070709133240.htm

    c)  Clinician bias — Persons of certain backgrounds being treated differently based on race, in public hospitals (again — funded by US taxpayer dollars)
    http://www.youtube.com/watch?v=6Pi0xDhIILI
    http://www.annals.org/content/141/8/635.abstract

    Many of the issues that drive health injustices are, at a very basic level, tied to structural violence, historical processes (that denied basic rights to certain groups), and government conflicts of interests.  As these are problems that threaten the Bill of Rights and the spirit of the US Constitution, then the US government will, and should, be a relevant target of action and advocacy; doing so is not being too reliant on “big government” or “begging the government for money.”

    Doing so is protecting the US Bill of Rights and spirit of the US Constitution. Our ability to do so is what makes this country (sound the violin) the best in the world.  : – )

    Jokes aside — there are room for both approaches.  The key is identify which issues are the product of true injustices and which are the niche, boutique health issues. While this would present a new debate, I’d argue that this debate is more constructive than the one we are having, which paints the issue in a big government vs civic society framework.

    The more painful debate is the one that gets after what defines an injustice. Another hypothetical:

    A hard-working American family grows up next to a toxic waste dump created by a corporation that occupies under the corporate welfare system and has full protection of the law. The community in which this dump is placed is lower-middle class, overworked, has access to poor schools and resources and lacks the time (let alone educational capital) to create and organize a movement to remove this waste dump.

    The fundamental question is this:

    Do you think this is fundamental violation of the spirit of the Bill of Rights and US Constitution?

    If you do not, than we have a different disagreement.

    If you do, then you’d agree that this is a government-supported (or even protected) injustice, which is grounds for government-focused advocacy.

    The neat thing is: even if you do agree that government is a fair target for advocacy, that does not mean that civic society cannot act as well; it most certainly can and should. This is why I find your argument useful and relevant.

     

    Thanks again for this article! Look forward to reading more of your work!

    • Anonymous

      Brandon,
      Thanks for your thoughtful comment. Your framework contrasting remedy for injustice vs. special interests is a very constructive idea. I am still chewing on it to better understand how its application would play out.
      I agree that government and civil society are not mutually exclusive in general or as they apply to healthcare.
      I also agree that corporate welfare and farm subsidies are bad policies. If the government didn’t try to pick winners, we wouldn’t have to worry about the negative health consequences of its meddling.
      There is a lot of nuance that I still need to think through. I look forward to continuing the conversation. Here are some the questions I am asking myself:

      Does NIH research count as a remedy for injustice or boutique interest?

      How about stem cell research, which has both federal and state funding?

      What are the most effective ways for government to remedy health injustices when a remedy is needed?

      If you have any answers I am interested to hear them. Also, do you believe that all corporations by definition benefit from corporate welfare or are you referring to boutique handouts and subsidies?

      Thanks again, -Zach