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https://jamanetwork.com/journals/jama/fullarticle/2775793

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Differences in cancer rates between ethnic groups

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Differences in cancer rates between ethnic groups

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This article discusses the differences in cancer incidence and outcomes between ethnic groups. These differences vary by racial group and by cancer type. For example, African Americans have a 50% higher incidence of myeloma, stomach, prostate, and liver cancer than Americans of European decent. While cancer development is much more than just genetic inheritance, I think it is important to continue research in the possible genetic differences of tumorigenesis and continue to identify heritable genes that increase the risk for different cancers. Genetic testing for racial groups that have a higher chance of having certain genes could help identify risk earlier for individuals in those populations. This could help populations at risk become aware of their genetic susceptibility. Hopefully, this type of research can function to improve government health policy and reduce racial disparities by making sure that at risk individuals can have better access to preventative care, genetic testing, screening, and catch the cancer earlier in development.
-Haneen Qunbar

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Dissecting Systemic Racism in Health Care 

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Dissecting Systemic Racism in Health Care 

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A couple of months ago, I had a lecture on the "Principles of Epidemiology and Public Health." I remember looking at the graphs taken from the American Heart Association and noting that the incidence of developing coronary heart disease or myocardial infarction was higher in black men compared to their white counterparts. I thought to myself, "So this means that race is a risk factor in heart health." At the time, I took the information that was presented to me at face value and didn't bother reading further or asking myself why that was the case. I finally realize that maybe race isn't a risk factor after all, but racism could be.

Higher premature mortality rates in the black community aren't due to an inherited genetic flaw present in people of African descent, but rather a result of institutionalized racism present in the health care system. This may be because the health care system was built on an ideology designed to disproportionately discriminate on the basis of race. Credible institutions such as the American Heart Institution suggest the slavery hypertension hypothesis as a possible link to higher blood pressure in African-Americans. This theory argues that Africans have evolved to inherit genes that favor sodium retention to survive in the dry climates of their original habitat, but enhance underlying pathology when they migrate. However, pathophysiological data has shown that salt-resistant individuals retain just as much sodium as their salt-sensitive counterparts, but do not develop hypertension. Moreover, having higher sodium levels is not enough to cause hypertension alone. This shows that genetic explanations for health disparities between races stem from a racist ideology. Furthermore, by grouping certain disorders with certain races, physicians may implicitly employ racial signifiers that can lead to falsely diagnosing pathologies.

Biological racism persists in almost every field of medicine. The glomerular filtration rate (GRF) is a measurement used by clinicians to assess renal function and diagnose kidney-related diseases. The GRF is estimated through equations such as the CKD-EPI and MDRD, which take into account factors such as sex, age, weight, serum creatinine, and race. Including a racial coefficient to calculate the GFR is problematic because it estimates that the GFR is closer to normal for a black person compared to a white person of the same age, weight, and creatinine level. This creates a lower disease severity for black people, resulting in them being diagnosed with end-stage renal disease much later than their white counterparts, leading to higher disease mortality. Race is used in these equations as a proxy for muscle mass (crucial for estimating creatinine levels), without a concrete explanation for why race may be related to an individual's muscle mass. Why can't medical students be taught how to calculate muscle mass instead of using equations embedded with medical racism?

In a statement made by black neurosurgeons in the U.S. regarding the outrage and unrest reflected in recent protests, it is made evident that racism is a public health crisis. Through anecdotal evidence, they highlight a vicious circle in which members of the black community are intentionally subjected to neurotrauma, causing death or damage to the brain or spinal cord, which can result in a life-long commitment to surgical procedures. This widens the pre-existing socioeconomic gap by increasing unemployment rates and limiting access to insured health care in the black community. This made me wonder if biological hypotheses for racial disparities in health were a cover-up for a much bigger issue, i.e., the public health system.

Take the COVID-19 pandemic. During this time of uncertainty and unpredictability, one thing has been certain in the U.S. health care system: Black lives are being lost at a disproportionate rate. African-Americans make up 13 percent of the U.S. population and account for 24 percent of COVID deaths where the race is known, a rate that is two times higher than their population demographics. However, these statistics are not surprising for many researchers. Dr. Marcella Nunez-Smith, who is the director of the Equity Research and Innovation Center at Yale School of Medicine, states that these COVID-19 racial disparities were "expected" and a result of "pre-pandemic realities." This makes it apparent that the black community was already at a disadvantage prior to the start of the pandemic.

The system was intricately built to put certain races at a disadvantage, so the first step in dismantling racist policies and practices would be to educate medical students about it. Since we are the future of health care, it is our duty to better the system for our black patients. One way of doing this would be by revising what is taught in medical schools. Instead of implying that Africans are genetically inferior, we should be taught about the racial bias that stems from this hypothesis and how it may negatively affect our patients. In a study published by PNAS in 2016, it was found that about half of the medical students and residents endorsed false beliefs about biological differences between black and white patients, such as "black people's skin is thicker than white people's skin," resulting in a flawed assessment of pain perception and treatment in black patients. This shows us how rooted racial biases may result in inaccurate treatment outcomes. In order to uproot these biases, medical trainees must be taught to recognize and address them first. The willingness to learn and revise our beliefs will bring us one step closer to vanquishing racism in the field of medicine.

If I could simplify it to one equation, this is what it would look like: lack of access to quality health care + social inequities + higher mortality rates + underrepresentation in health care jobs + genetic explanations for biological inferiority + unimportance of acknowledging racial biases medical school curricula + using race as a risk-factor = systemic racism in health care.

It's time to change the equation. Let's start to view race as a social construct, not a biological one. Let's develop plans to address the social determinants of health and prioritize equal access to health care for everyone. Let's raise awareness about systemic racism in health care and confront racist policies. Let's educate medical students about racial biases and the impact they can have on patient care. Let's start having conversations that make a difference. Let's aim for health equity.

So the next time medical students look at graphs of the incidence of developing heart disease, they do not just see race as a risk factor but instead understand the structural racism from where it stems.
Rhea Raj is a medical student and can be reached on Twitter @rhearaj123. Image credit: Shutterstock.com

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Vineet Arora, MD, Shikha Jain, MD, Laura Zimmermann, MD, Ali Khan, MD, Amisha Wallia, MD, and Eve Bloomgarden, MD

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Dissecting systemic racism in health care

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A couple of months ago, I had a lecture on the "Principles of Epidemiology and Public Health." I remember looking at the graphs taken from the American Heart Association and noting that the incidence of developing coronary heart disease or myocardial infarction was higher in black men compared to their white counterparts.

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Racial Disparity in use of Anti-Nausea Meds with Chemotherapy

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Racial Disparity in use of Anti-Nausea Meds with Chemotherapy

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Sex, Race and Ethnic Diversity in the US among healthcare professionals

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Sex, Race and Ethnic Diversity in the US among healthcare professionals

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Data collected by the US Department of Health and Human Services Health Resources and Services Administration (HRSA) from 2011-2015 demonstrates the diversity among 159,824,883 individuals in the health care industry. This literature shows how the health care industry is predominately composed of White individuals (64.4%). This article provides a good starting point in addressing why the other races (35.6%) are present in such small percentage. Understanding what factors have helped the White demographic, and what factors have hindered the people of color would shed light on how to combat the inequality in this field. Having a health care system with true diversity promotes better patient care and a better perspective in what disparities are present within the community. Multiple sources have shown that patients are more open and are more likely to take preventative actions coming from a health care provider that looks like them. We have come a long way, but we also have a long road ahead of us. The only way all of us can thrive is by working together!

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Here is a book that I think all of us entering the medical profession should read, it's about the experiments that the medical establishment has performed at the expense of people of colour, like the Tuskegee syphilis experiment and how African Americans were exploited by whites and shipped to medical schools across the country as cadavers.

While we have come a long way, it goes without saying that we have not gone far enough, and we should think about how the past of our future career has made lives worse disproportionately. Topics like this are painful for white people, like me, but we must be able to reckon with our past in order to make the future more equitable.

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Doctors look to these digital calculators to make treatment decisions, but they can end up denying black patients certain care.

A dialysis specialist donned personal protective equipment before treating a patient with coronavirus in a Maryland hospital. Kidney function is one of several factors doctors evaluate differently according to race. Credit... Win Mcnamee/Getty Images

Unbeknown to most patients, their race is incorporated into numerous medical decision-making tools and formulas that doctors consult to decide treatment for a range of conditions and services, including heart disease, cancer and maternity care, according to a new paper published Wednesday in the New England Journal of Medicine.

The unintended result, the paper concludes, has been to direct medical resources away from black patients and to deny some black patients treatment options available to white patients.

The tools are often digital calculators on websites of medical organizations or - in the case of assessing kidney function - actually built into the tools commercial labs use to calculate normal values of blood tests. They assess risk and potential outcomes based on formulas derived from population studies and modeling that looked for variables associated with different outcomes.

"These tests are woven into the fabric of medicine," said Dr. David Jones, the paper's senior author, a Harvard historian who also teaches ethics to medical students.

"Despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice," he wrote.

The paper is being published at a tense moment in American society as black communities, disproportionately affected by the coronavirus, protest unequal treatment in other areas of their lives.

Dr. Jones said he believed the developers of the tools, who often are academic researchers, are motivated by empiricism, not racism. But the results, his analysis found, have often led to black patients being steered away from treatments or procedures that white patients received.

The paper included a chart listing nine areas of medicine where there are race-based tests, and it analyzed the consequences. For example, it reported, labs routinely use a kidney function calculator that adjusts filtration rates for black patients. With the adjustment, black patients end up with slightly better rates than whites, which can be enough to make those with borderline rates ineligible to be on a kidney transplant list.

An online osteoporosis risk calculator endorsed by the National Osteoporosis Foundation, among others, calculates chances of a fracture differently for black and white women. Black women end up having a score that makes them less likely to be prescribed osteoporosis medication than white women who are similar in other respects.

An obstetric calculator based on observational data concludes that black women who had a previous cesarean birth are less likely to have a successful vaginal birth in a subsequent pregnancy.

Dr. Jones added that it is time to stop what amounts to racial profiling in medicine. "We need to get off this train," he said.

The New England Journal paper built on a collection of recent findings and assessments, including those in a recent paper about kidney function by Dr. Nwanaka Denise Eneanya and her colleagues at the University of Pennsylvania.

To determine how well kidneys are working, doctors use a blood test that measures a protein called creatinine to estimate kidney filtration rate. Low filtration rates indicate a kidney problem.

Dr. Eneanya's team noted that patients with a filtration rate of less than 30 were referred to kidney specialists. They gave an example of a white patient whose level was 28, according to the calculator. A black patient with the same creatinine level would get a race correction under the formula that raises the level to 33. Consequently, the black patient would not get a referral to a specialist.

The same effect could make some black patients ineligible to be put on a list for a kidney transplant - those with filtration rates of 20 or above are ineligible.

The formula originated with data from a federal study more than two decades ago that asked if a low-protein diet reduced the risk of kidney disease (it did not, the study showed). The study included precise measures of kidney function and creatinine levels, which let researchers use creatinine to estimate kidney function. The formula fit the data best when they included an adjustment for black patients.

In a more recent paper, in 2009, the researchers combined data from a number of studies to devise an improved formula, asking which variables made the formula best fit the data. Race popped up again.

"The formula was widely adopted," said Dr. Melanie Hoenig, a kidney specialist at Harvard Medical School.

One of its principal authors, Dr. Lesley Inker, a kidney specialist at Tufts Medical Center, said she hears the critics.

"What we say is, 'You're right. I understand the difficulty in assigning race,'" Dr. Inker said.

She is working on developing a more accurate formula that does not include race. She added that black patients should be told that their race alters the calculation and should be given an option to have their race excluded.

But, she says, the current formula also can be an advantage for black patients. Those with filtration rates below 30 are ineligible to be prescribed metformin, the first line drug for diabetes, and SGLT2 inhibitors, a more recent class of diabetes drugs.

One problem, is that it is not clear how race is determined. It shows up in medical records but, said Dr. Peter Reese, a kidney transplant specialist and epidemiologist at the University of Pennsylvania, "I worry that in some situations they look at you and assume."

With the formulas, there is no accounting for people of mixed race, as the authors of the New England Journal paper and other doctors have noted.

Even if race does have a real affect on lab values for creatinine, why assume it is because of the genetics that determine skin color, some experts asked.

"It could be diet or any of a number of things," Dr. Hoenig said, noting that a large protein-heavy meal can temporarily raise creatinine levels.

One often cited explanation is the belief that black people are more muscular than white people, and muscles can release creatinine into the blood. In a recent paper, Dr. Vanessa Grubbs, a kidney specialist at the University of California, San Francisco, tried to trace the origins of that belief and found only a few decades-old studies that did not even measure muscle mass directly, including one saying black children are thinner than white children.

A group of medical students at Harvard has been trying to change the approach to assessing kidney function, with some success.

The group, including Leo Eisenstein, Danika Barry and Cameron Nutt, had heard Dr. Jones in lectures saying race was a social construct and then went into the clinic, where they were told to use a formula that corrects for race in assessing kidney function.

Instead of complaining, Dr. Hoenig told the students, why not go to the leadership and suggest a change? Labs could simply not list race when sending in blood tests for creatinine - in that case the formula's default would be the level for whites. Or they could give results as a range and explain to patients that the numbers are an estimate.

A few years ago, Dr. Hoenig and the students made the rounds to executives at Beth Israel Medical Center.

"We went to the chief of medicine, we went to the head of clinical labs, we went to the head of the kidney division, we went to a lot of people and spun our story," she said. "They were open to it."

In 2017, Beth Israel dropped the race factor in calculating kidney function. But despite pleas for a change, no other hospitals have followed suit.

Recently though, San Francisco General has replaced race as a factor with a choice of values for kidney function depending on the doctor's assessment of whether the patient was muscular or not.

Advocates of change like Dr. Hoenig say they think part of the problem is resistance to changing a system that has become part of medicine.

Dr. Darshali A. Vyas of Massachusetts General Hospital, who is first author of the New England Journal paper, said the ultimate goal is for doctors and researchers to rethink the assumption that they can use a patient's race in making medical decisions.

"This is a challenge to the field about how we think about race and what our default assumptions are about race," she said.

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Race Is Used in Many Medical Decision-Making Tools

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Doctors look to these digital calculators to make treatment decisions, but they can end up denying black patients certain care. Unbeknown to most patients, their race is incorporated into numerous medical decision-making tools and formulas that doctors consult to decide treatment for a range of conditions and services, including heart disease, cancer and maternity care, according to a new paper published Wednesday in the New England Journal of Medicine.

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How Biased Genetic Databases Can Harm Everyone's Health

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How Biased Genetic Databases Can Harm Everyone's Health

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This article from 2019 discusses how genome-wide association studies, GWAS, only have 22% representation of non-European descendants on average. 78% of the people in these studies are of European descent. However, based on previous studies such as research into the genetic basis of sickle cell anemia, we know people not of European descent can have mutations that are endemic to that population, while not being present at noticeable levels in other populations at all. Racial disparity in these studies and databases reduces the breadth of information researchers have, and only hinders development of new treatments. Further, treating black people based on research gathered about white people can do real harm, such as in the prescription of warfarin mentioned in this article.

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Modern humans originated on the continent of Africa more than 300,000 years ago, and subsequent generations migrated across the land, with groups intermarrying or splitting apart. Sometime around 80,000 years ago, a small number of descendants left the continent and radiated around the globe, taking with them just a subset of the genes and genetic variation that their ancestors had developed.

Yet genetic studies are now dominated by that subset, according to a new article in Cell.

If we don't include ethnically diverse populations, we are potentially going to be exacerbating health inequalities.

As of last year, 78 percent of the people included in the most prominent form of genomic research - genome-wide association studies (GWAS) - were of European ancestry. But worldwide, Europeans and their descendents make up just 12 percent of the population.

According to the researchers, heavily biased genetic databases could - and do - lead scientists and doctors to diagnose conditions or prescribe treatments that might be relevant to people with European genes, but not for people from other racial backgrounds.

"If we don't include ethnically diverse populations, we are potentially going to be exacerbating health inequalities," said Sarah Tishkoff, study coauthor and a human geneticist at the University of Pennsylvania.

How this affects health care equality

Any two humans in the world share about 99.9 percent of their DNA with one another, but that 0.1 percent of variation is incredibly important. That variation can be just single replacements here and there in the four-letter code of a person's genetic material, and can make the difference between a gene that works to encode healthy proteins, and a gene that fails and makes a person sick.

Genetics interact with other factors, like diet, activity and access to resources, all of which determine a person's health. And health treatments that don't take the variations of genetically diverse populations into account can cause problems.

Just a few tiny changes in the genetic code can have large effects on the effectiveness of a drug like the blood-thinner warfarin, and therefore the amount of medication that will be effective and safe for a patient.

But those changes are only well-studied in Europeans, the researchers argue. Algorithms that help doctors prescribe the right amount of warfarin for an individual patient work fairly well for people with European genes, but are far less accurate for African Americans.

In one study of 274 African American patients, one of those genotype-guided algorithms consistently prescribed too much medication, resulting in a high risk of uncontrolled bleeding.

Without better data and tailoring to more gene variations, prescriptions designed to help patients, in the end, could hurt them instead.

Why this matters

The more of these genes that we can study, the more likely we are to discover ones that are particularly useful for understanding how a disease works

The lack of genetic diversity is "a social injustice, and a missed scientific opportunity," said Esteban Burchard, who is a physician and epidemiologist at the University of California, San Francisco, and was not involved in the new paper. "But it's not surprising."

In his own research, Burchard sees similar disparities in studies of Americans in Puerto Rico. When he proposes research on minorities, he said, committees and funding organizations ask how that research will generalize to the white population. "They never ask the other way around."

Biased genetic databases are also missing out on research into human genetic variation that could actually benefit everyone, the study's researchers said.

Populations of humans acquire distinct genetic mutations over time, through selection or genetic drift. The more of these genes that we can study, the more likely we are to discover ones that are particularly useful for understanding how a disease works, or how a treatment for a disease might be created.

One genetic mutation found through studying people of African descent, for example, quickly became a prime target for helping scientists understand how some cholesterol is regulated in the body.

"It's a beautiful example where a rare mutation is suppressing a gene," said University of Pennsylvania geneticist Giorgio Sirugo, who also contributed to the paper.

Once researchers figured out why that suppression of that gene lowered cholesterol, they were able to create treatments to mimic the effect, leading to drugs that could work for people of any racial background.

How to fix it

It's no accident that there is a disparity in the people represented in genetic studies.

It's partially convenience, the researchers said. When studies are mostly performed in the U.S. or Europe, researchers are likely to use the racial majority where they live.

The human reference genome, for example - the result of the $2.7 billion Human Genome Project - was constructed from samples taken in Buffalo, New York, an area with predominantly European ancestry. Its limitations are becoming more and more clear.

Also, even when studies branch out from institutions in the U.S. and Europe, they may be faced with challenges in finding medical equipment and facilities that will be precise and reliable for quality genetic research. In rural areas of developing countries, researchers may not have access to reliable electricity, let alone microscopes, refrigerators or more sophisticated laboratory equipment.

But it's also based in historical trauma. Minority populations have been faced with serious medical abuses, like the infamous Tuskegee Study in which hundreds of black men with syphilis were observed by doctors but left to die of the disease untreated. For black communities in America, trust in medical institutions is still marred by those injustices.

In light of that history, "this has to be done right. Ultimately, [the people who participate] should be the ones to benefit from the information we gain," Tishkoff said.

Meanwhile, Burchard said, it's a tense climate in research and politics when it comes to talking about race at all.

While race cannot and does not divide humans into biologically distinct populations, it is a useful proxy for genetic and social patterns for researchers studying public health, Burchard said.

And yet conversations about race, diversity and social justice are increasingly polarized even within the scientific community.

"All of our work focuses on racial differences, but this is the first time in my career at UCSF that I've been nervous about giving a talk," Burchard said.

Although the National Institutes of Health are working toward closing the genetic research disparity, at least for minority populations in the U.S., the researchers maintain that there is a lot of work to do. Most of that work involves funding studies that investigate the genetics of scientifically underrepresented people around the globe.

"By not including diversity we are missing out on great opportunities to make novel discoveries and to be more inclusive of world populations," Burchard said.

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Genetic research has a white bias, and it may be hurting everyone's health

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Around 80,000 years ago, a small group left Africa and radiated around the globe, taking with them a subset of their ancestors' genetic variation. Now, that subset dominates genetic and health studies worldwide.

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ALBUQUERQUE, N.M. - A prominent women's hospital here has separated some Native American women from their newly born babies, the result of a practice designed to stop the spread of COVID-19 that clinicians and health care ethicists described as racial profiling.

Lovelace Women's Hospital in Albuquerque implemented a secretive policy in recent months to conduct special coronavirus screenings for pregnant women, based on whether they appeared to be Native American, even if they had no symptoms or were otherwise at low risk for the disease, according to clinicians.

The hospital screens all arriving patients for COVID-19 with temperature checks and asks them whether they've been in contact with people who have the illness. But for soon-to-be moms who appeared to be Native American, there was an additional step, according to clinicians interviewed on the condition they not be named.

Hospital staff would compare the expectant mother's ZIP code against a list of Indian reservation ZIP codes maintained by the hospital, known informally as the "Pueblos List," a reference to New Mexico's Pueblo Indian tribes. If the pregnant woman's ZIP code matched one on the list, she was designated as a "person under investigation" for COVID-19, the clinicians said.

Lovelace does not use rapid COVID-19 tests, and babies were sometimes born before asymptomatic Native American mothers' test results came back from the lab, a process that can take up to three days. As a result, the hospital separated Native American newborns from their asymptomatic mothers in at least a half-dozen cases, one clinician said.

Such separations deprive infants of close, immediate contact with their mothers that doctors recommend.

"I believe this policy is racial profiling," one clinician said. "We seem to be applying a standard to Native Americans that isn't applied to everybody else. We seem to be specifically picking out patients from Native communities as at-risk whether or not there are outbreaks at their specific pueblo or reservation."

The Navajo Nation and several Pueblo tribes in New Mexico have recorded some of the highest per capita rates of COVID-19 infection in the nation. In response to the pandemic, the state has designated several counties as hot spots, including some that are home to tribes with large numbers of cases. But 10 of the ZIP codes on the Lovelace Pueblos List reviewed by New Mexico In Depth and ProPublica do not fall within those hot spot counties, nor do all tribes within those ZIP codes have a high rate of infection.

A Lovelace spokeswoman acknowledged screening patients by geography, but she would not confirm or deny the existence of a policy based on ZIP codes as described by staff. Lovelace, whose owner is Nashville, Tennessee-based Ardent Health Services, is Albuquerque's largest privately owned hospital system.

"Part of our screening process includes identifying and testing patients who reside in high-risk areas such as nursing homes and regional hot spots of COVID-19 cases as recommended" by the Centers for Disease Control and Prevention, Lovelace spokeswoman Whitney Marquez wrote in a May 21 email.

But CDC guidelines for evaluating COVID-19 risk among pregnant patients do not mention geography or ZIP code of residence. The guidelines instead state that only pregnant patients with COVID-19 symptoms or recent high-risk contacts with COVID-19 patients should be treated as suspected cases.

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"Regardless of pending test results, pregnant individuals who are asymptomatic at the time of admission and have no history of high-risk contact should not be considered to be suspected cases," the CDC guidelines note.

In a follow-up email, Marquez said Lovelace's residential geography screening applied to all patients: "Any patient admitted to the hospital for any reason from a designated hot spot region is tested for COVID-19 as a PUI (person under investigation), per CDC guidance."

Marquez's claim was disputed by several clinicians who work in the hospital. Only ZIP codes with significant populations of Native Americans appeared on the list. Patients who did not appear to be Native American were not subject to further screening based on the ZIP code list, they said.

The two other large hospitals in Albuquerque said they did not have a policy like the one described by clinicians at Lovelace. Mothers are not determined to be suspected COVID-19 cases based only on their home ZIP code or their appearance, officials at Presbyterian Hospital and the University of New Mexico Hospital said. Nor are asymptomatic mothers' newborns separated for isolation pending test results at those other hospitals.

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At Lovelace, only women who appear to be Native American were singled out for the additional examination, even if they showed no symptoms and had not been in contact with a person who has tested positive for the illness, clinicians said.

"This isn't about where you live or if you live in a hot spot - it's about whether someone thinks you look Native," a clinician explained. "The only people for whom we've been told to check ZIP codes are patients who appear to be Native."

Health care ethicists said the practice described by the clinicians raises troubling questions about bias, trust and informed patient consent.

Saskia Popescu, a senior infection prevention epidemiologist at George Mason University in Fairfax, Virginia, said such policy decisions wouldn't make sense from an infection control or epidemiology perspective, and they could create or exacerbate trust issues toward health care among Native American patients.

"There is a lot of room for error and a lot of assumptions," she noted. "You're assuming their mailing address is where they live, and they've been exposed or not exposed based on where they live. It doesn't match public health guidance."

Popescu said she understood why the hospital might place someone under investigation if they came from high-risk settings like nursing homes, but she questioned how a case could be made for doing so based on a home ZIP code.

"I don't really know how well you can make the case that if a mom is asymptomatic, if she is reporting no known exposures to sick people, how you can make the case for keeping that baby in the NICU, separated," Popescu said.

The "Pueblos" List

A copy of the Lovelace list reviewed by New Mexico In Depth and ProPublica contains names of tribes next to each of 22 associated ZIP codes. Native Americans have a much higher COVID-19 rate overall than other populations in New Mexico, but most of the tribes on the list have a low prevalence of the illness. For instance, the ZIP code for Cochiti Pueblo had recorded zero cases as of Tuesday; the ZIP code for Picuris Pueblo had just one. An additional eight ZIP codes had 7 or fewer cases.

An internal communication reviewed by New Mexico In Depth and ProPublica suggests the intent was to include all Indian reservations on the ZIP code list. But if so, the list is inexplicably incomplete.

All 19 New Mexico Indian Pueblos and the Mescalero Apache tribe are named next to a ZIP code on the list, and the Navajo Nation is named next to five ZIP codes. (Several Pueblo Indian tribes share some ZIP codes.) But missing from the list are the Jicarilla Apache tribe and three outlying Navajo communities: To'hajiilee, Ramah and Alamo. Also missing are numerous ZIP codes in the northwest part of the state with significant Native populations - and COVID-19 outbreaks.

Marquez did not provide a list of "designated hot spot" regions or ZIP codes despite repeated requests, other than stating that New Mexico hot spot regions "have been determined by the New Mexico Department of Health."

But the state defines COVID-19 geographic hot spots by county, not ZIP codes, spokesman David Morgan wrote in an email.

"Hospitals have the latitude to decide on who to test, but no testing decisions should be made arbitrarily solely on the basis of race or ethnicity," State Epidemiologist Michael Landen wrote in an email Thursday.

Referring to a map on the state Health Department's online COVID-19 dashboard, Human Services Department spokeswoman Jodi McGinnis Porter listed the counties of San Juan, McKinley, Sandoval, Bernalillo and Doña Ana as state-designated hot spots.

Twelve of the 22 ZIP codes, which are home to 14 tribes on the list, have very few positive COVID-19 cases, according to publicly available Health Department data. Those ZIP codes are shaded green, or have no color, on the state data portal, signifying they have the lowest number of cases compared with other areas.

In other words, the Pueblos List contains low-risk ZIP code areas that include particular tribes but do not include other ZIP codes falling within counties deemed to be COVID-19 hot spots by the state - even those that contain large swaths of the heavily hit Navajo Nation.

Separating Babies

Usually, Lovelace officials announce new policies by emailing links to staff. But that was not done in this case. Instead, supervisors read the policy aloud at the beginning of each shift, clinicians said.

The verbal readings didn't mention that Native American mothers had to provide informed consent to be tested or separated from their newborn, a clinician said. That ambiguity appears to have caused confusion among staff.

One clinician said that Native American mothers were given an opportunity to decline separation from their infants.

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But another clinician said some staff did not know patients had an option to do so for several weeks in April and May. "I don't believe that patients were given an opportunity to decline testing or separation from their babies," that clinician said. "This is a violation of informed consent, which is a foundation of modern health care."

Marquez, the hospital spokeswoman, disputed the claim. She said that Lovelace provides all patients suspected or confirmed of having COVID-19 with information about the risks of remaining with their newborns. "Some patient[s] opt to keep their baby with them," she said.

At least part of the issue lies in the type of tests done to detect COVID-19. Several Albuquerque hospitals, including Presbyterian and the University of New Mexico, use new rapid COVID-19 tests that yield results as quickly as two hours.

Lovelace, however, uses slower tests. Marquez would not explain why Lovelace did not deploy more rapid tests.

Nicolle L. Gonzales, a Navajo nurse midwife who worked at Lovelace for two years, first heard about the ZIP code policy from a colleague at the hospital last month.

Gonzales, who founded and directs the Changing Woman Initiative, a Native American women-led health collaborative in Santa Fe, New Mexico, said informed consent is an important concern for Native American patients

"You know, if you're a Native person in an all-white setting, how do you speak up for yourself?" she asked. "There is no way to measure whether you're being racially profiled or racially excluded from a norm [of treatment] that's happening or not happening with others."

Several Lovelace clinicians voiced concern about newborn separations and delayed breastfeeding, which can reduce the odds of successful breastfeeding later on, denying health benefits to mothers and their babies. For babies, breastfeeding can benefit immune system and brain development. Mothers who breastfeed have lower risks of breast cancer.

Read More

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"Unless there is a life-threatening issue, we do not take babies from their moms," a clinician explained. "It is standard practice and policy for babies to be immediately put on the mother, before and during the cutting of the umbilical cord, and to leave them there for at least an hour."

For some health care ethicists, the policy described by the Lovelace clinicians recalled the federal government's long, troubling history of separating Native American infants from their mothers. For others, it appeared uncomfortably similar to the disparate treatments of minorities in previous epidemics.

"This raises the specter of the HIV/AIDS pandemic in the 1980s," said Barbara Gurr, associate professor of women's, gender and sexuality studies at University of Connecticut and author of "Reproductive Justice: The Politics of Healthcare for Native American Women." Gurr recalled a fear-driven bias against Haitian immigrants and gay men as HIV/AIDS spread. "Certain people were understood to be the bearers of the disease, in this kind of contaminating way, right? I think we're running the risk of doing it again in the COVID pandemic."

Ethicists also worried about the lingering effects of a policy based on ZIP codes. It could deter Native Americans from seeking hospital obstetric care, said Ann Mongoven, associate director of health care ethics at the Markkula Center for Applied Ethics at Santa Clara University in California.

"There's a real concern that this policy could discourage people who absolutely should have hospital births," she said.
Bryant Furlow is a reporter for New Mexico In Depth.
Have You Given Birth at Lovelace Women's Hospital in Albuquerque?

We're reporting on birth and newborn care at Lovelace Women's Hospital. We'd like to hear from you to help us understand your experiences. We appreciate you sharing your story, and we take your privacy seriously. ProPublica is gathering this information for our reporting, not for immediate publication.

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A Hospital's Secret Coronavirus Policy Separated Native American Mothers From Their Newborns

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ALBUQUERQUE, N.M. - A prominent women's hospital here has separated some Native American women from their newly born babies, the result of a practice designed to stop the spread of COVID-19 that clinicians and health care ethicists described as racial profiling.

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Racism & Inequality for African American Health Care

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Racism & Inequality for African American Health Care

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What You Should Know

Of the more than 20 million people who have gained coverage under the ACA, 2.8 million of them are African-American-and yet, this population is still more likely to be uninsured than white Americans.

The average American family spends around 11 percent of household income on health care premiums and out-of-pocket costs, but that amount approaches 20 percent for African American households.

Because African Americans tend to be poorer than other demographic groups on average, public health insurance programs such as Medicaid are vital to ensure affordable health care and healthier outcomes-yet fourteen states have resisted Medicaid expansion, mostly in the South.

Even with improved access to medical care under the ACA, the disparities in health outcomes between African Americans and whites are stark. African-American women are three times more likely to die of pregnancy-related causes than white women, for example, and the African-American infant mortality rate is twice the rate for white infants.

Certain social determinants of health, such as poverty, income inequality, wealth inequality, food insecurity, and the lack of safe, affordable housing have important implications for health risk and the ability to attain health insurance coverage for African Americans.

Another important social factor leading to poor health outcomes and economic disadvantage among African Americans is racism, because not only is it a stressor, leading to wear and tear on the body, but it also impacts who gets what in America, particularly health care.

The nation is at a moment when more progressive health care reform might be possible; any health care reform needs to take these inequities into account in recreating a health care system that will serve all Americans.

The American health care system is beset with inequalities that have a disproportionate impact on people of color and other marginalized groups. These inequalities contribute to gaps in health insurance coverage, uneven access to services, and poorer health outcomes among certain populations. African Americans bear the brunt of these health care challenges.

African Americans comprise 13.4 percent of the U.S. population. Over the span of several decades, namely since the Civil Rights Acts of 1964 and 1968, they have been able to make notable strides in American society. According to the Economic Policy Institute, educational attainment has greatly increased, with more than 90 percent of African Americans aged 25-29 having graduated from high school. College graduation rates have also improved among African Americans. When it comes to income, gains have been made as well, but African Americans are still paid less than white Americans for the same jobs and lag significantly behind when it comes to accumulating wealth. And as for home ownership, just over 40 percent of African Americans own a home-a rate virtually unchanged since 1968.

African Americans are also living longer, and the majority of them have some form of health insurance coverage. However, African Americans still experience illness and infirmity at extremely high rates and have lower life expectancy than other racial and ethnic groups. They are also one of the most economically disadvantaged demographics in this country.

This report will examine the state of health care coverage for African Americans and shed a light on important social factors that uniquely impact their health outcomes. In an effort to draw implications from leading health care reform plans, recommendations are made for the way forward in ensuring that the physiological and social impacts of racism are not omitted in efforts to secure truly universal health care coverage in America. African Americans are one of the most politically engaged demographics in this country. Addressing their unique challenges and perspectives, including the pervasive impacts of racism, must be included in health reform efforts.

Coverage Gains-and Obstacles-for African Americans Under the ACA

The Affordable Care Act (ACA) has helped to ensure health care coverage for millions of Americans. The uninsured rate among African Americans declined after the law was implemented: of the more than 20 million people who have gained coverage under the ACA, 2.8 million of them are African-American. Yet, this population is still more likely to be uninsured than white Americans: as of 2018, the uninsured rate among African Americans was 9.7 percent, while it was just 5.4 percent among whites. African Americans were more likely to be covered through employer-sponsored or private health insurance: 55 percent of African Americans used private health insurance in 2018, while 41.2 percent were enrolled in Medicaid or some other type of public health insurance.

While coverage expansions under the ACA have hastened the progress toward universal coverage, the continued high cost of many coverage options means that access to affordable health care is still a challenge for many Americans-particularly African Americans.

The average family spends $8,200 (or 11 percent of family income) per year on health care premiums, and out-of-pocket costs for things such as office visit copays, prescription drugs, and surprise or out of plan medical bills continue to wreak havoc on the financial security of families. For African Americans, the average annual cost for health care premiums is almost 20 percent of the average household income-a major cost to bear, when taking into account income inequality and other economic challenges for this demographic.

The high cost of coverage has kept the number of uninsured and underinsured unacceptably high: of the 27.5 million people that still lack health insurance coverage, 45 percent cite cost as the reason for being uninsured. Furthermore, the Commonwealth Fund estimates that an additional 87 million people (adults aged 19 to 64) are underinsured; that is, they have coverage, but their plan leads to unusually high out-of-pocket costs relative to income that can lead to a strain on personal finances or even debt. Of these underinsured adults, 18 percent are African-American.

Systemic Health Care Challenges That Reform Must Address

Despite coverage gains, remaining health care challenges exist that have a disproportionate impact on African Americans. The lack of Medicaid expansion in key states, health disparities, and health care provider shortages make it incredibly hard to address America's health care needs in a comprehensive way. And while these challenges are factors that touch many Americans in various parts of the country, the gravity of them is uniquely seen in the South, and among the African-American population.

The South's Stubborn Approach to Medicaid Expansion

The Medicaid program has been a lifeline for low-income Americans, pregnant people, the elderly, and people with disabilities. It is jointly funded by states and the federal government, and has been operating for fifty-four years. As of August 2019, the program covered 68 million people, with African Americans making up about 20 percent of Medicaid enrollees. Because African Americans tend to be poorer than other demographic groups on average, public health insurance programs such as Medicaid are vital to ensure affordable health care and healthier outcomes. In states that have not expanded Medicaid under the Affordable Care Act (ACA), African Americans and other people of color are most likely to fall within a coverage gap -meaning they earn too much to qualify for the traditional Medicaid program, yet not enough to be eligible for premium tax credits under marketplace plans.

The states that have not expanded Medicaid are largely concentrated in the southern region of the United States.

Under the ACA, Medicaid eligibility was expanded for adults with incomes up to 138 percent of the federal poverty level (FPL). This expansion was originally written into the ACA as a requirement for all states, but due to a 2012 Supreme Court ruling in National Federation of Independent Business v. Sebelius, it is now just an option for states. To date, thirty-seven states (including the District of Columbia) have expanded Medicaid, either through traditional means or the Section 1115 waiver process. The states that have not expanded Medicaid are largely concentrated in the southern region of the United States. (See Map 1.)

Map 1

In the South, African Americans are disproportionately represented. According to the U.S. Department of Health and Human Services Office of Minority Health, 58 percent of the African-American population lived in the South as of 2017. They are also more likely to be uninsured, with Texas, Florida, and Georgia being home to the largest shares of uninsured African Americans. Some states have also proposed draconian work requirements as a condition for the participation in the Medicaid program. These requirements can only serve to stigmatize enrollees, deny coverage, and discourage low-income people from the support they desperately need. In Arkansas-one of nine states to date with 1115 waivers approved by the Trump administration allowing fully implemented work requirements- 18,000 low-income people lost health care coverage as a result. This coverage loss comes as no surprise, because the use of work requirements for other safety-net programs, including Temporary Assistance for Needy Families (TANF), has proven them to be ineffective in their stated goal-promoting employment-yet highly effective in reducing program eligibility. Medicaid work requirements for three states have been struck down by the courts. Due to the failure to expand Medicaid, the South is now home to the nation's sickest people, and is where health disparities between whites and people of color are the most pronounced.

Disparities in Health Outcomes

Increases in health insurance coverage under the ACA have improved access to medical care and have been linked to better outcomes for African Americans, such as earlier diagnosis and treatment of certain cancers. However, disparities still exist across health conditions when comparing African Americans and whites, including maternal mortality, infant mortality, heart disease, diabetes, cancer, and other health issues. Social factors, including economic disadvantage, inequities in education, and lack of access to health care, impact a person's ability to lead a healthy and productive life. For people in American society that experience racism and inequality in their daily lives, and throughout the lifespan, the impact of social factors on health are the most grave.

Even with improved access to medical care under the ACA, the disparities in health outcomes between African Americans and whites are stark. African-American women are three times more likely to die of pregnancy-related causes than white women (see Figure 1). The African-American infant mortality rate is twice the rate for white infants (see Figure 2). African Americans are more likely to die from cancer and heart disease than whites, and are at greater risk for the onset of diabetes. However, death rates for African Americans with cancer and heart disease did drop over a fifteen year period. Across many chronic illnesses, however, African Americans are still more likely to die compared to other racial and ethnic groups. Homicides are also a leading cause of death for African Americans. In fact, African American children are ten times more likely to die by gun violence than white children (see Figure 3).

Figure 1

Figure 2

Figure 3

Health Care Provider Shortages

Due to residential segregation, majority African-American and Hispanic areas are more likely to lack hospitals and other health care providers. Therefore, place matters. When health care providers are located within majority African-American and Hispanic neighborhoods, they tend to offer lower-quality care. Often, people of color find themselves relying heavily on community health centers, emergency rooms or outpatient care, and community-based providers due to the lack of available primary care and mental health providers in a given geographic area. Traveling outside of the immediate geographic area to access health care may be an option for some people, yet this can be a challenge due to lack of access to transportation for those with limited incomes or for those living in rural areas.

It is not difficult to locate where-and for whom-provider shortages are a serious concern. The Health Resources and Services Administration (HRSA) defines Health Professional Shortage Areas (HPSAs) as geographic, population, or facility-based designations that are indicative of health care provider shortages. Designations are made by the following health disciplines: primary care, dental health, and mental health. Federal regulations dictate the threshold for shortages by calculating the ratio of population to provider in order to identify high need areas. In 2018, there were 17,657 geographic areas, populations, and facilities identified by HRSA as not having enough health care providers. Mental health and primary care were the disciplines in the shortest supply.

Medically Underserved Areas and Populations (MUA/Ps) are another designation by HRSA. They are geographic areas and populations that lack adequate access to primary care providers. MUA/Ps identify specific populations that are likely to experience barriers to health care including the homeless, low-income people, people eligible for Medicaid, Native Americans, and migrant farmworkers. Designations are made by calculating the population-to-provider ratio, percent of population below the federal poverty level, percent of population over the age of 65, and the infant mortality rate.

Important Considerations for Health Care Specific to African Americans

Certain social factors, also referred to as social determinants of health, have important implications for health risk and the ability to attain health insurance coverage. Poverty, income inequality, wealth inequality, food insecurity, and the lack of safe, affordable housing are just a few. Another important social factor leading to poor health outcomes and economic disadvantage among African Americans is racism, because not only is it a stressor, but it impacts who gets what in America, particularly health care.

Racism's Wear and Tear on African Americans

African Americans have endured racism within American society for hundreds of years. Studies conducted over time have been consistent in proving that racism not only impacts social stratification, but also the ability of African Americans to be healthy-both mentally and physically. This burden-a burden that is indeed inescapable for black and brown people in this country-causes African Americans to die prematurely and experience chronic illnesses and mental health challenges at higher rates than white Americans.

According to a study published in the journal of Psychoneuroendocrinology, racist experiences bring on an increase in inflammation in African Americans. This increase in inflammation raises the risk of becoming chronically ill. The researchers of the study assert that, because the body's response to stressors-such as the adversity of racism-results in compromising systems that are critical in fending off disease, exposure to racism over long periods of time caused the health of African Americans to suffer greatly with chronic illness as the body's defenses were down due to inflammation. Chronic illnesses associated with experiencing racism include heart attack, neurodegenerative disease, and metastatic cancer. The study participants had similar socioeconomic backgrounds, which eliminated poverty as a stressor-a social factor that has also been linked to the onset of illness.

Similar findings were yielded in some of the earliest studies looking at the impact of racism on the health of African Americans by University of Michigan public health researcher Arline Geronimous. After looking at biological factors associated with exposure to stressors, Geronimous hypothesized, in what is also referred to as the weathering hypothesis, that African Americans experienced health deterioration because of those stressors. Geronimous examined the allostatic load scores-that is, the cumulative wear and tear on the body's system brought on by the repeated adaptation to stressors-for adults aged 18-64. African Americans were found to have higher scores than white Americans. Once again, poverty was ruled out as a factor, due to the fact that the higher allostatic loads existed among African Americans of various socioeconomic backgrounds. Geronimous concluded that racism, and the burden of coping with it across the lifespan, leads to differences in health among African Americans and white Americans-including the onset of chronic illness and premature death.

In addition to instigating poor health outcomes among African Americans, racism also creates barriers to economic opportunity and uneven access to health care. Even the health care system itself perpetuates racism and bias toward African Americans. This has been well documented with examples, including differences in pain management and treatment of African Americans when compared to whites experiencing the same health conditions, use of African Americans' bodies in medical experimentation, and racial bias in health algorithms for the purpose of guiding health decisions and assessing health care costs. Actions like these have led to a general distrust of the health care system within the African American community. Racism cannot be divorced from the other social factors outlined in this report, which give reason to the fact that African Americans are disproportionately affected by them.

Poverty

Across economic indicators, vast disparities exist between African Americans and whites that mirror the proportions seen in health disparities. Due to structural barriers, African Americans are more likely to be poor than white Americans and are less likely to have a full-time worker in the household. The poverty rate among African Americans was 20.8 percent in 2018, higher than for any other racial or ethnic group in the United States, and more than twice the poverty rate of white Americans. Growing up in poverty is also associated with toxic stress, of which the impact can reach crisis levels when a person is also grappling with the toxic stress brought on by racism. When African Americans are able to attain work, they are more likely to work in low-paying jobs that lack important benefits, including health insurance and paid leave. The African-American poverty rate also shows how critical public programs such as Medicaid are to helping ensure access to health care for this population. Because of these factors, Medicaid expansion helps more African Americans gain coverage than any other group.

Household Income Inequality

African-American households have significantly lower household income than white households. The average household income for African Americans in 2018 was $41,361, while it was $70,642 for white households. (See Figure 4.) African Americans tend to make less than whites for the same jobs, pointing to unequal pay as a contributing factor in the gap in household income. Even when taking into account similar education levels, workers of color are consistently paid less than white workers.

Income is a major factor in a family's ability to access health care, which can make up a significant share of household spending in terms of insurance premium costs and out-of-pocket costs.

Figure 4

The Wealth Gap

When it comes to accumulating wealth, the numbers are even more grim-white families now have approximately ten times the wealth of African-American families, on average. (See Figure 5.) Research shows that the wealth gap impacts African Americans across the income and education spectrum, making it harder for them to own homes or build retirement savings. And while African Americans on average have less total debt than whites, the wealth gap means they are more likely to have costly, high-interest debt obligations. High health care costs and surprise medical bills can negatively affect an African-American family's ability to reduce or eliminate debt, and ultimately the ability to create wealth-which could impact a family for generations.

Figure 5

Food Insecurity

Food insecurity is also an issue affecting many African Americans and has important implications for health outcomes and economic well-being. Food insecurity occurs when a household or family lacks access to adequate nutritious food. This happens due to the lack of financial means to purchase healthy food or by living in impoverished geographic areas void of grocery stores with whole, fresh foods. Neighborhoods that lack access to nutritious foods are also referred to as food deserts. The ten U.S. counties with the highest food insecurity rates are all at least 60 percent African-American. African Americans experience hunger at twice the rate of white Americans, including one in four African-American children. Hunger can also lead to chronic illness and has been associated with low-birth weight, diabetes, cancer, pregnancy complications, and mental distress.

The Lack of Safe and Affordable Housing

Housing and neighborhood safety are also important economic indicators that can impact health. Unfortunately, far too many African Americans have to grapple with neighborhood violence and environmental factors (such as a lack of clean water, exposure to lead paint, and pollution) that can negatively impact both their mental and physical health. Additionally, a relative lack of affordable housing options and home ownership continues to plague the African-American community, largely due to longstanding racist practices such as redlining and subprime mortgages. The lack of affordable housing puts a financial strain on families and can pull resources away from necessities like food and medical care. For homeless and transient communities, it can be almost impossible to access health care or maintain adequate health regimens. Despite comprising just 13.4 percent of the total U.S. population, African Americans make up 40 percent of the homeless population, and are an overrepresented part of this group in every state.

Overview of Health Care Reform Plans

Several health care reform proposals have been introduced by members of U.S. Congress and by 2020 presidential candidates. In this section, the most widely known and promising plans that have gained traction and media coverage in recent months are highlighted.

Medicare for All

Medicare for All is a signature single-payer plan originally authored by Senator Bernie Sanders, setting forth a vision for major structural change of the health insurance system. It has since been endorsed and supported by Representative Pramila Jayapal (who introduced the House version of the legislation), Representative Alexandria Ocasio-Cortez, Senator Elizabeth Warren, Senator Kamala Harris, Senator Cory Booker, and a host of other progressive policymakers. It calls for a single federal program with comprehensive benefits for all U.S. residents that would replace all private insurance, Medicaid, Medicare, and the Children's Health Insurance Program (CHIP). The plan would be financed by taxes and eliminate premiums and cost-sharing or out-of-pocket costs, leading to major cost-savings for consumers in the long run. Taking into account the vast economic challenges for African Americans, savings in health care costs could help lead to better economic outcomes. In turn, health outcomes could also improve due to more comprehensive coverage available to all.

Comprehensive health benefits under Medicare for All include medically necessary services in thirteen benefit categories, including home and community-based long-term care, dental care, hearing, vision care, comprehensive reproductive health care (including abortion services), and transportation to health care appointments for people with disabilities and low-income people. Drug prices would be negotiated annually and a formulary would be established. Medicare for All would also prohibit balance billing, also known as surprise billing, which happens when health providers bill patients for the difference in the total cost of a health care service and the amount paid by an insurer.

Public Insurance Option

Public option plans call for a federal insurance option. These plans essentially build upon the ACA by adding a new option available to those seeking coverage. Former vice president Joe Biden has been an advocate for this plan and has included it in his platform as a 2020 presidential candidate. There are several versions of the public option-some that would leave the marketplace subsidy structure unchanged, and others that would enhance it for all plan participants. Some public option proposals even go so far as to eliminate individual heath insurance plans created by the ACA. A key difference in the Biden plan, when compared with Medicare for All, is that it retains current public and private insurance sources. For people who like or prefer their private insurance, they can maintain it under the Biden plan.

The Biden plan would retain major components of the ACA including protections for people with pre-existing conditions, premium subsidies, and Medicaid expansion, along with offering public insurance as an option to anyone who wants it. A public insurance option was initially part of the ACA as introduced in Congress but was taken out of the legislation later in the negotiations process. Biden's public option plan also aims to reduce the cost of prescription drugs by allowing importation of them from other countries, empowering Medicare to negotiate drug prices, and supporting the development of generic drugs. It would also offer tax credits to middle class families to help lower the cost of health insurance and eliminate the 400 percent federal poverty level income cap. The plan would eliminate balanced billing and be financed through capital gains taxes on rich individuals. Biden's plan also includes protecting access to contraception and abortion rights, as well as the promise to adopt California's strategy of public-private partnerships nationwide in addressing the U.S. maternal mortality crisis as major steps in building upon the ACA. Various versions of public insurance option legislation have also been introduced in Congress by Senator Ben Cardin, Representative Cedric Richmond, Senator Tim Kaine, Representative Jan Schakowsky, and others.

Sixty-one percent of white respondents in a November 2019 Gallup poll prefer the private health insurance system, whereas 57 percent of nonwhite respondents prefer government-run insurance. The cost of health care is still of major concern for those people with private health insurance, more so than for those with public insurance sources.

Ensuring Health Care Access and Affordable Coverage for African Americans

The single payer and public option insurance plans outlined in this report were developed in a way to help fill coverage gaps and get as many people insured as possible. The plans aim to do this by emphasizing affordability-addressing the high cost of insurance premiums and limiting out-of-pocket costs, including surprise medical bills, prescription drugs, and fees for direct health care services. Unfortunately, current health reform plans fall short in adequately addressing racism in the health care system. This stands in the way of ensuring health equity, namely full insurance coverage and quality health care access for African Americans.

Cost to the individual is certainly an important factor in the conversation about health coverage and ensuring that people can access the health care services they need. However, in order for African Americans to attain meaningful insurance coverage and access to quality health care, the health care system must be transformed to better address the unique social factors that cause African Americans to remain in the coverage gap and how racism plays a role in their health outcomes. Furthermore, the economic challenges African Americans face serve as barriers to sustaining comprehensive coverage which can lead to poor health outcomes. It is simply not enough for insurance coverage to be affordable or even "free"-it must also serve as a tool in progress toward systemic change and equity that will help African Americans get ahead.

To do this, getting to universal health care coverage will require that the following steps be taken:

Promote health equity by adequately addressing racism, bias, discrimination, and other systemic barriers within the health care system. To do this, policymakers must acknowledge the historical foundations of racism and ensure that health care providers, personnel and staff are substantively trained to recognize and eliminate all forms of bias in the health care system. Accountability measures at both the individual and systems levels should be in place, including measures that link payment, professional certification, and licensure to quality of care.

Incorporate evidence-based tools to adequately address health disparities that focus on quality of care that extend beyond health insurance coverage, including the impact of racism on the health of African Americans throughout the life course. In health reform efforts, policymakers must take into account the social determinants and address how they impact health by working across sectors, including social support agencies and community-based providers with patient-centered approaches to care. Racist practices, such as those in the treatment and pain management of African Americans, should be eliminated.

Protect and expanding access to insurance coverage and comprehensive benefits and bolstering the ACA benefit provisions and nondiscrimination guarantees. These efforts should include preserving coverage for people with pre-existing conditions by further codifying protections that ensure benefit inclusion and design decisions that do not result in limiting access to care. Policymakers should also build on the essential health benefits package to include important health care services currently omitted, such as long-term care and dental care.

Protect the integrity of Medicaid, an important health insurance source for African Americans, by denying state efforts to impose draconian stipulations on coverage for enrollees such as work requirements. In order to close the coverage gap among African Americans, policymakers must also implement targeted strategies to incentivize and ensure Medicaid expansion in all southern states.

Ensure access to quality providers and addressing provider shortages and hospital closures by anticipating increases in demand and working with HRSA to implement concrete strategies to close gaps in health care access for medically underserved areas/populations and health professional shortage areas. Strategies should include plans to not only increase the health care workforce, but also diversify it and offer technical support and training to minority-serving hospitals.

Support the development of a robust, diverse, and culturally competent health care workforce by encouraging and facilitating diversity throughout the health care system and care teams, and adequately training all staff to be culturally sensitive. Payment rates and coverage guidelines for health care coverage should be developed in a way that supports fair, living wages and pay equity in the health care professions and jobs.

Limit the cost of premiums and out-of-pocket costs, helping to make health insurance more affordable for individuals and families across the income spectrum. This should include limiting deductibles, prescription drug costs and other point-of-service charges, and completely eliminating surprise medical bills. All of these costs are major barriers to health care access, particularly for individuals and families with limited incomes.

Strengthen access to trusted community-based providers currently available through safety-net programs, such as Medicaid, Medicare, and the Children's Health Insurance Program (CHIP). These programs are often lifelines for marginalized communities and they disproportionately serve people of color. Policymakers should develop health reform plans that are intentional in ensuring continued access to these vital sources of care, as well as seamless coordination with health insurance payers for people with coverage seeking care from community-based providers.

African Americans stand to make significant gains if health reform is done right. The statistics outlined in this report paint a grim picture. Regardless of the progress made in recent decades, far too many African Americans still struggle to lead healthy and economically secure lives. This is due to the long-standing effects of racism, which touches all African Americans, regardless of socioeconomic status. These effects can be reversed, but it will take real commitment and systemic change. Health care reform must be part of the effort.

Tags: health care, income inequality, wealth inequality, racism, racial inequality, African americans

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Racism, Inequality, and Health Care for African Americans

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What You Should Know Of the more than 20 million people who have gained coverage under the ACA, 2.8 million of them are African-American-and yet, this population is still more likely to be uninsured than white Americans.

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Article raises awareness regarding maternal health and negative outcomes associated with African American mothers. An issue i believe should be addressed. We need better support for maternity health in general.

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Medicine continues to advance on many fronts, yet basic health care fails hundreds of women a year who die during or after pregnancy, especially women of color. Black mothers die at a rate that's 3.3 times greater than whites, and Native American or Alaskan Native women die at a rate 2.5 times greater than whites, according to a report out this week from the Centers for Disease Control and Prevention.

Yet, the report concluded, roughly 3 in 5 pregnancy-related deaths are preventable. The racial disparity in maternal death rates is a dramatic argument for prevention efforts that address diverse populations, says Dr. Wanda Barfield, director of the Division of Reproductive Health and assistant surgeon general in the U.S. Public Health Service.

About 700 women died each year from complications of pregnancy in the U.S. between 2011 and 2015, either while pregnant or up to a year after delivery.

The CDC's principal deputy director, Dr. Anne Schuchat, notes that every death reflects a web of lost opportunities including lack of access to health care, missed or delayed diagnoses, and failures by doctors or nurses to recognize warning signs.

"Big-picture, system-related changes are needed," Schuchat said in a press briefing. She noted the process won't be easy and could require remaking systems that have been in place for years.

The CDC says health care providers need to help patients better manage chronic conditions that could be exacerbated by pregnancy. More than a third of pregnancy-related deaths were due to cardiovascular conditions, according to the CDC report.

Women who died during childbirth itself typically suffered severe bleeding or what's called an amniotic fluid embolism, where amniotic fluid leaks into the mother's bloodstream.

During the week after delivering their babies, women who died experienced severe bleeding, extremely high blood pressure or infection.

And during the year after having their baby, women died from complications of hypertension, stroke or a weakening of the heart muscle, called cardiomyopathy.

Pregnant and postpartum women need to understand warning signs so they can identify problems early on and seek timely treatment, the CDC report warns. For hospitals and health systems, the CDC says medical responses to emergencies should be standardized so providers are crystal clear about how to proceed with treatment.

When addressing racial disparities, it's important to note the difference in underlying chronic disease risk, Barfield says. Cardiovascular disease is more common among black women and can occur at earlier ages than in white women, she says. It may be that cardiovascular symptoms are never identified in these women or that they simply cannot overcome social factors such as a lack of transportation to access health care, she says.

In addition, Barfield says that some inequities can be explained by variation in hospital quality. "This can mean that effective interventions may not be occurring for black women," she says, or that the timing of the intervention may not be appropriate.

"Minority women are delivering in different and lower-quality hospitals than white women," she says, adding that this could clearly affect outcomes.

Barfield suggests doctors and other health care workers "cross communicate" and discuss potential weaknesses in the system to shore up better prenatal and postnatal care for minorities. "There's a perception among many black women that the care they receive during and after pregnancy is different than it is for their white counterparts," she says.

There is "an implicit racial bias in health care," Barfield says, and black women often feel they are not being heard when they raise concerns about a particular aspect of their care.

Today it's becoming more clear that disparities have more to do with racism than race, says Neel Shah, an OB-GYN and a professor at Harvard Medical School.

For a long time there was "this baked-in assumption" that there was something different genetically among black women leading to their higher rates of maternal mortality, he says. But "genetically we are all the same," he says, and the evidence is strong that it is the chronic effect of the stress of racism, or " weathering" as some researchers describe it, that takes its toll on pregnancy, childbirth and care for a newborn after birth.

And this stress can take place in medical settings as well, where unconscious bias can affect quality of care, according to NPR's 2017 investigative report. NPR and ProPublica collected 200 stories from African American mothers and found that unconscious bias in health care was a "constant theme."

What's more, racial disparities and the increased risk for black women are not ameliorated by social status, income or education, says Shah.

The story of tennis star Serena Williams is an example of that. In the days after giving birth to her daughter, Williams developed a life-threatening pulmonary embolism, or blood clots in the lung, as she told Vogue last year.

There is some progress being made in addressing maternal mortality, says the CDC's Schuchat. Many states and local communities nationwide have already implemented changes that could "serve as a model for the nation" to make a difference in pregnancy-related death. So far, 13 states have taken the lead, and Schuchat hopes to expand these programs to other states.

And there is growing awareness of the issue in the private sector and among physicians. Shah co-founded March for Moms Association, a coalition of more than 20 organizations dedicated to increasing public and private investment in the well-being of mothers. The organization has a march planned in Washington, D.C., on May 11.

The American College of Obstetricians and Gynecologists recently published Practice Bulletin, Pregnancy and Heart Disease, which offers guidance to doctors about screening, diagnosis and management of heart disease for women during pregnancy and the postpartum months.

Bringing down maternal mortality rates will require a concerted, communitywide effort, Schuchat notes.

"We have the means to identify problems and close gaps and prevent deaths," Schuchat said.

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Why Racial Gaps In Maternal Mortality Persist

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Black and Native American women die of pregnancy-related causes at a higher rate than white women. Researchers say the gaps are driven by unequal access to health care and the experience of racism.

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Social disparities in healthcare and how to overcome those

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Social disparities in healthcare and how to overcome those

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Presentation made by the University of Mississippi Pharmacy School. It discusses common Social Inequities and how they can be identified and overcome.

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Common Bias in Healthcare and how to overcome these disparities

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https://www.bmc.org/healthcity/policy-and-industry/physicians-role-racial-equity

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Health is more than medicine and clinical care is a small aspect of what keeps someone healthy. Social environment, the political context, and socio-economic status play a much bigger role in a person's health. Racism, as a system that distributes unequal access to resources, power, and privilege based on a social construct called race, is a major social determinant of health. It explains why Black Americans do poorly on health outcomes compared to white counterparts who have the same social-economic status or education level. Recent data suggests Black Americans are dying from COVID-19 at 3.5 times the rate of their white counterparts. Another analysis calculated that if the COVID-19-related death rate among all minority groups were the same as in White Americans, an estimated 13,000 Black Americans, 1,300 Latino Americans, and 300 Asian Americans would still be alive right now. With that being said, we cannot reach health equity without racial equity.

As physicians, we need to address our bias and prejudice and question our privilege. Being anti-racist is an ongoing process, so we have to educate ourselves and hold each other accountable.
It is not serving our patients to treat them, only to send them back to the social environment that made them sick. Click To Tweet
We need to identify how we benefit from the system, and then use our privilege to fight for equity. We need to question the medical curriculum and prepare physicians to be anti-racist. Don't send a syllabus with only white scholars to your students. Ask for minority representation, especially Black women, on your conference panel.

It is impossible to separate our clinical work from work addressing racial inequity: It is not serving our patients to treat them, only to send them back to the social environment that made them sick. On a much bigger level, we need to hold our society and the greater medical system accountable for health disparities due to racist policies that prevent access to care for everyone. We need to require our elected officials to have concrete, actionable plans to address police brutality, mass incarceration, food deserts, homelessness, and education inequality - terrible problems that disproportionately affect Black people.

Healthcare providers are in a unique position to research and understand these and other drivers of poor health in diverse patient populations. We should use this privilege to challenge the system and provide evidence-based solutions to policymakers. Our patients are often voiceless. This is why we need to use our status to advocate for them and make it clear that there will be zero passes for racist behaviors and policies, whether in our hospitals or their communities. Research and programs initiated by Black scholars will go a long way to help this cause. But because racism provides unequal access to resources and power, many black physician researchers have a hard time getting funded. Therefore, it is especially important for people who call themselves allies to invite more minorities to join the decision-making process with full support behind their voices.

We become physicians because we work hard and show a lot of resilience. Nevertheless, we are among the most privileged people. We cannot stay indifferent to the lives of those we care for.

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The Physician's Role in Racial Equity | HealthCity

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Health is more than medicine and clinical care is a small aspect of what keeps someone healthy. Social environment, the political context, and socio-economic status play a much bigger role in a person's health. Racism, as a system that distributes unequal access to resources, power, and privilege based on a social construct called race, is a major social determinant of health.

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