As February comes to a close, we want to pause and recognize Black History Month. Often Black History Month is accompanied with celebrations of history and accomplishments of black Americans. Many of these opportunities are the result of continued advocacy for civil rights and equity in labor, education, transportation, housing and health. Within this spirit of equity and advocacy, Community Catalyst is committed to weaving a health equity lens into our entire advocacy and programmatic work. Our vision of health equity is to create a society in which everyone has a fair opportunity to achieve their full health potential, regardless of the individual’s or population group’s race, color, religion, national or ethnic origin, immigration status, class, age, disability, veteran status, sexual orientation, gender, gender identity or gender expression.  

As we strive to achieve our vision of health equity, we must recognize the current reality of the health outcomes that black Americans face. Health outcomes can be impacted by number of different factors, from individual behaviors to systemic influences – the latter often referred to as social determinants of health, “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care. Unfortunately, black communities have shown significant disparities across a number of health outcomes for many years. And many of these disparities are a result of inequities within structural systems and social determinants of health. Some cases in point: African American babies are twice as likely to die before age one as white babies; 73 percent of black children are more likely to be obese than white children; 60 percent of black adults are more likely to have diabetes than white adults.

Health disparities are detrimental to the health of our communities and country. Poor health outcomes in any group lead to poorer overall outcomes in our society’s educational attainment and economy. In order to understand the existing disparities among racial and ethnic communities and find effective solutions, we need to ensure that policies are in place that require the collection and reporting of data on disparities. Inadequate health data can mask unique patient and population needs and undermine effective interventions. In complete opposition to the goal of gaining more insight on disparities, a bill introduced in Congress last month specifically restricts using Federal (HUD) funds to "design, build, maintain, utilize, or provide access to a Federal database of geospatial information on community racial disparities or disparities in access to affordable housing." Bills like this are harmful to low-income communities of color and push our society backward rather than forward towards health equity.

As we continue to think about advocacy efforts to defend the Affordable Care Act and Medicaid, it’s also very important for advocates to consider the implications and impacts harmful policies can have on vulnerable communities.  Under the ACA, the uninsured rates for blacks dropped from 21 percent in 2013 to 13 percent in 2016. In states that decided to take up Medicaid expansion, blacks are less likely to be uninsured.  Defending the ACA and Medicaid is more than just defending access to coverage; it is about protecting human rights and moving towards realizing our vision for health equity.

Reflecting on Black History Month reminds us not only of the fights of the past, but of the continued fight forward for equity.

Amidst the noise of the national political landscape, it is important to remind ourselves that February is Black History Month. While this month serves to celebrate the accomplishments of black people in America, it is also a reminder of how inequality has, and continues to, plague many black communities. Health inequity constitutes one of the many systemic forces that perpetuate the marginalization of the same community we celebrate for its undeniable contributions to American society. In the words of civil rights playwright and activist James Baldwin, “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

The challenge: Why must we act? Disparities persist.  2017 marks 53 years since the passage of the Civil Rights Act of 1964, key legislation that outlawed de jure discrimination based on race, color, religion, sex or national origin. And yet, half a century later, we still suffer the consequences of de facto discrimination across all axes in health such as disparate health outcomes, and/or access to affordable quality care. In fact, according to a Kaiser Family Foundation brief “disparities in quality of care are not getting smaller. Over time, the health disparities between Whites and African Americans, Hispanics, Asians, and American Indians/Alaska Natives has either remained unchanged or worsened for most of the core qualities measures of health.” The longstanding weight and trauma of racism has long-term consequences across the lifespan for people of color.

Adverse Childhood Events: A metric for trauma.  One health disparity among children garnering growing concern and attention is prolonged adversity (or trauma) in the absence of positive adult caregiver support. Researchers have used Adverse Childhood Experiences (“ACEs”) to categorize the many forms of early trauma. Not surprisingly, Black and Hispanic children – even at the highest income levels – are more likely than their white peers to experience adversity. Work led by Harvard University’s Jack Shonkoff illustrates how exposure to trauma and stress negatively affects brain development before the age of three. Further, research shows that trauma can have long-term psychological and physiological health impacts that exacerbate health disparities over generations if left untreated. This is a stunning reminder of the urgency surrounding health care coverage and access for children and parents throughout the life cycle – from preconception to a child’s transition into adulthood.

Despite this substantiated research, it is not standard practice for medical providers to inquire about the trauma history of their patients. Moreover, there are not enough financial incentives put forth by insurance payers to do so. A first step is to focus on parents, assessing their exposure to stress and trauma and providing tools and resources as they develop as parents and caregivers of young children.

But what can ACEs screening tool do?  There is reason to keep hope. We know that resilience – the ability to overcome hardship – can attenuate some of the impacts of significant adversity. Kids who have a supportive relationship with an adult caregiver are better able to build resilience. And while historically, African-Americans/Black people have found ways to build such resilience by employing faith, hope and community, these supports are simply not enough for many of our most vulnerable families and children who face persistent adversity.

These disparities emphasize the importance of implementing more targeted programmatic intergenerational policies and programs that focus on addressing the needs of both vulnerable parents and their children together in order to create cycles of opportunities for more families.

A validated ACEs screening tool would serve the dual purpose of employing a more strategic approach that properly identifies and provides social service resources to at-risk families in order to build supportive caregiver relationships.

Concrete pathways to action:  This is a difficult political environment, but it is more imperative than ever to focus on the health and wellness of our communities. If we know that our communities shape the conditions families face, and that families shape the conditions children grow up in, then we must urgently support families in strengthening their capacity for resilience so they can build that capacity amongst our children. In that vein, the children’s health team at Community Catalyst has developed an issue brief to support a shared understanding of ACEs, trauma and stress and the multi-generation policy approaches that support healthy families.

Over the next few months the children’s health team will be conducting a review of ACE’s legislation and programs across the country. This will include investigating initiatives that are Community-, Provider- and legislative- led to inform an issue brief for consumer health advocates and provider communities. We hope the resulting issue brief will serve as a call to action with the dual purpose of reminding us all why health equity work matters, and what vehicles providers, consumers and legislators can use to advance the ACE agenda.

Nana Yaa Misa, Children’s Health Initiative Intern

Minnesota Dental Clinic Shows the Daily Economic Benefits of Dental Therapy

Welcome to a new Community Catalyst blog series describing different perspectives on dental therapists at work. Dental therapists are highly trained oral health practitioners that work with dental teams similar to the way physicians’ assistants work with medical teams. Along with providing education and preventive services, they are able to perform common dental procedures such as filling cavities and, in limited cases, removing decayed teeth.

Dental therapists have been practicing in the U.S. for more than 10 years. They have improved access to dental care for underserved communities in Alaska since 2005 and in Minnesota since 2011. Vermont and Maine recently authorized them to work in those states. Oregon and Washington have hired dental therapists as part of demonstration projects within tribal communities, and nearly a dozen more states are considering authorizing the providers.

As Executive Director of Children’s Dental Services, a clinic that provides dental care to children from low-income families in Minneapolis, I have to balance the huge need for subsidized dental care with the need to keep our clinic financially solvent so it can stay open.

In 2009, members of the Minnesota legislature approved the licensure of dental therapists, highly trained mid-level professionals who can perform routine and preventative services through team-based care, often compared to the way physician assistants work in medicine.

When the bill passed, dental therapists were touted as a cost-effective way to increase access to dental care and our clinic was one of the first to put them to work in our state. It turned out to be a wonderful decision – both for our young patients and the financial stability of our clinic.

We use a team-based approach. Dentists supervise our dental therapists and because they are paid less than dentists our clinic is able save over $60,000 each year. That savings goes directly back into serving our patients. This had a significant impact to our bottom line during the recession allowing us stay open when other clinics were being forced to close.

But it is not all about saving money. Our dental therapists have provided care to more than 18,000 patients, decreasing our wait time for appointments by two weeks, and increasing overall patient time with the provider by 10 minutes. Furthermore, we’ve been able to extend our reach to remote parts of the state increasing dental access to those most in need.

In addition to these care delivery improvements, we are now using dental therapists as part of our emergency room diversion program helping to reduce the number of people seeking dental care in the E.R, which is saving the state money.

I cannot imagine our clinic operating without these critical members of the dental care team. For us, they have proven to be a financially viable solution for making sure that low-income, uninsured and underinsured kids in our state have access to high-quality dental care.

Sarah Wovcha joined Children's Dental Services as Executive Director in January of 2001. She holds a Juris Doctorate from the University of Minnesota Law School and a Master of Public Health degree from the She was one of the first employers of dental therapists in the state of MN.

Yesterday, House Republican leadership released another "replacement plan," the Obamacare Repeal and Replace Policy Brief and Resources. After nearly seven years, Republicans continue to call for replacement of the Affordable Care Act but have yet to put forward a plan that offers any clarity to consumers, let alone the same protections and coverage gains currently available under the Affordable Care Act (ACA). The announcement of yet another messaging document masquerading as a replacement plan continues that trend. Once again, in spite of much fanfare and self-congratulation, House Republicans still failed to present agreed-upon legislative language. The white paper released yesterday includes only high-level descriptions on some possible aspects of replacement while leaving key details missing.

Despite Republican protestations, the ACA has greatly improved the affordability of coverage available to consumers. The ACA has provided low- and moderate-income individuals and families with hundreds of billions of dollars in tax cuts to help make health insurance more affordable. And a majority of consumers using Healthcare.gov have been able to find plans with premiums below $100 after taking into account financial assistance.  Although most marketplace enrollees like their coverage, the main thing people want from health reform is lower out-of-pocket costs.

Yet instead of building on the current law, Republicans keep on releasing proposals that would undermine the coverage gains we have made under the ACA, leave families with fewer benefits and higher out-of-pocket costs, and dismantle Medicaid’s critical safety net. Rather than a detailed consensus for specific legislation, the Obamacare Repeal and Replace Policy Brief simply reiterates a grab-bag of recycled Republican policy ideas that fail to provide true protection for consumers.

For example, the tax credits offered under the Republican plan would not be adjusted based on income. Under this proposal, a family earning $150,000 would get just as much help as a family earning $25,000. People with fewer resources would likely get far less help affording premiums than they get today, which essentially amounts to a tax increase for these families and would likely put coverage out of reach for them. The proposal also encourages use of health savings accounts to supplement high-deductible health plans and the establishment of high-risk pools to aid individuals with pre-existing conditions. None of these policies makes coverage more accessible or affordable to low-income consumers and in reality would increase out-of-pocket costs when consumers can least afford it.

The GOP plan would also dismantle the Medicaid program as we know it. Their proposal to phase out Medicaid Expansion would reverse the progress made under the ACA to extend health insurance to low-income adults. And the proposal to cap and slash federal funding through per capita caps and block grants would push massive costs onto states and erode the health care safety net, putting coverage at risk for tens of millions of children, older adults and people with disabilities.

The Republican leadership's continued reliance on concept papers and rhetoric – instead of real proposals backed by concrete numbers and analysis – shows just how far they are from having a plan that can deliver on the promises they have made to replace the ACA with something that is both better and cheaper. Ultimately, these plans are a distraction from the real issue at hand – whether Congress will vote for a reconciliation bill that takes coverage away from millions and raises costs for millions more without any consensus on what, if anything, will come next.

As the timeline for an Affordable Care Act (ACA) repeal bill continues to slip, many writers have written some variant of the idea that technical challenges with how to repeal the Individual Responsibility Requirement (IRR) without undermining the ban on pre-existing condition exclusions are a key stumbling block. Strictly speaking, this is not correct. It is not that Republicans cannot figure out an alternative to the IRR. Some combination of auto enrollment provisions and a late-enrollment penalty might be an adequate substitute given that the ACA requirement is somewhat porous to begin with.

There’s Still No Agreement…

The bigger problem is they cannot agree among themselves on with what or even whether to replace the ACA. Some want to continue down the original path of repeal now and replace later (and later could mean MUCH later--maybe never). Others want to wipe out most of the federal protections but essentially allow states that want to keep the ACA to ‘kinda sorta’ do that. Still others want to inject a "down payment on replace" into the initial repeal bill, which, of course, opens up fresh controversies over what should be in that down payment.

And controversy there will be. Based on previous policy statements and information on what House Republicans are vetting with the CBO, the policies that will likely emerge from the House include: high-risk pools; increased reliance on high deductible plans and Health Savings Accounts; changes to the ACA insurance tax credits that will make coverage less affordable for low-income people; and elimination of the guarantee of federal matching funds to states for Medicaid expenditures.

But There Are Dozens of Unanswered Questions

Implementing each of these policies requires many complex decisions. Consider high-risk pools. They were common before the ACA, but have never worked well in the past because inadequate benefits, high cost-sharing, high premiums, and enrollment caps have made them a poor vehicle for providing coverage to their primary market, which is composed of high-risk people with modest incomes. If Congress seeks to return to a reliance on pools, will they implement policies in an effort to overcome these historic shortcomings? For example, what benefits would be covered by high-risk pools? How much above market would premiums be for enrollees? Under what circumstances could insurers send people to the pool--would people need to be rejected first before they could access pool coverage? Would enough funding be available to keep premiums affordable, benefits robust and enrollment open, or would the new policy simply replay the shortcomings that have plagued past failed pools?

Capping Medicaid funds is, if anything, an even more complex undertaking. How would caps be calculated? How would they be adjusted over time? What, if anything, would states be allowed to do that they cannot do now to stay within the federal caps? Would the amount each state gets just be a reflection of past decisions made by states (which could disadvantage states that have been more aggressive at trying to reduce Medicaid spending), or will they reflect some more empirical standard? Would the federal matching formula remain essentially the same under the cap or would states be able to pull state dollars out of the system without losing federal funds, thereby increasing health system cuts? And, of course, there is the question of what will happen to the states that expanded Medicaid (and, for that matter, those that didn't)?

People Don't Like What's On the Republicans' Health Policy Menu

The common thread that unites all of these ideas is that they would increase costs and undermine access for people who are poorer and sicker. Just how badly would be determined by the other health policy debate that is roiling the ranks of Republicans: how much, if any, of the revenue raised by the ACA would remain to pay for benefits and how much is going to be spent on tax cuts for the wealthy. But it is no wonder that, with a policy menu that boils down to fewer people covered, higher cost-sharing, fewer jobs, more financial instability for health care providers and higher costs for state government, Republicans are not anxious to unveil their plans before the President's Day recess. In fact, many are doing everything they can to avoid the questions that are coming at them from angry constituents. Some may hope, given that many people don't know that the ACA and Obamacare are the same thing, they can confuse the public and escape accountability for undermining access and affordability. Those who don't want to see our health care system take a giant step backwards will have to make sure that doesn't happen.