BY NIRBAN SINGH AND AMY HELBURN

Introduction

Medicare Advantage (Advantage), originally conceived in 1997 during the Clinton Administration as ‘Medicare + Choice’, has progressively grown and become an established health insurance option for those 65 and older. According to data collected and aggregated by the Kaiser Family Foundation, Advantage has more than doubled in total enrollment between 2010 and 2021. In 2021 alone, 26 million people were enrolled in Medicare Advantage, which is over 40% of the total Medicare beneficiary population. In 2021, 85% of Medicare Advantage growth was concentrated among for-profit health plans, with UnitedHealthCare, Centene, and Humana leading the way.

Overall, the Medicare Advantage market is dominated by UnitedHealthCare, Humana, and CVS Health/Aetna, with this trio responsible for over half of all Advantage beneficiaries.As of October 2020, about 80% of Advantage enrollees directly purchased individual policies, while employer-sponsored Advantage enrollment has been steadily growing, comprising 18.1% of the Advantage market overall in 2020. Analysis from The Chartis Group indicates that half of all Medicare beneficiaries will be enrolled in Advantage plans by 2025, so the trio of existing leaders in providing Advantage plans may continue to innovate and profit immensely while new market entrants may grow their footprint rapidly, in response to growing demand.

Understanding the Policy Context

Originally enacted under the G.W. Bush administration in 2003, the Medicare Modernization Act (MMA) renamed Medicare + Choice as Medicare Advantage. This act also offered pharmaceutical drug benefits to Medicare beneficiaries for the first time through Medicare Part D via private, approved health insurers. The legislation cemented the notion that markets can, and should, regulate themselves and the federal government, i.e. CMS, would not be allowed to negotiate drug prices with pharmaceutical companies. As a resulting consequence, senior citizens were thrust into a newly organized Medicare market with private insurers offering HMO plans and managed care arrangements, within various budgetary limitations.

The Bush Administration emphasized that a ‘modernized Medicare’ would spark competitive forces among health insurers, ultimately delivering better forms of care at a lower price point than traditional Medicare. While the bill introduced new coverage options, it also limited members to switching plans only once annually. This condition effectively has dissuaded individuals from being proactive mid-year and discouraging activity outside of open enrollment periods. In 2018, 7 of 10 of Medicare beneficiaries did not compare Medicare plans, and that figure rises about 10-20% among minority, older, and low-income populations. Further, the MMA raised reimbursement rates to private insurers up to traditional Medicare enrollee spending. According to Public Citizen, in 2003, the pharmaceutical industry spent a record $109 million on federal lobbying and hired a record 824 lobbyists. PhRMA, a leading lobbying organization representing numerous brand-name pharmaceutical companies contributed greater than $16 million lobbying for the bill while HMOs and managed care plans themselves spent over $32 million in lobbying in 2003. Individually, the Blue Cross Blue Shield Association spent $8.1 million, while trade associations representing the health insurance industry spent an equivalent amount.

The rapid privatization of Medicare has been frequently attributed to a need for greater efficiency and better care options for senior citizens. However, the rise of Medicare Advantage has created an excess of health insurance options and resulted in economic outcomes that contradict the original rationale for the Bush Administration’s passing of the MMA. The Medicare Modernization Act is a clear-cut example of neoliberalism, a political ideology that favors free-market capitalism that is often espoused and enacted by political conservatives to deregulate industries. G.W. Bush touted the promise of affordability of prescription drugs and the federal government’s commitment to providing older adults with high quality healthcare experiences, all with the underlying intent of privatizing the administration of Medicare, by shifting spending from traditional Medicare to Advantage.

The pharmaceutical industry retained their freedom from pricing restrictions as the MMA restricted any negotiations between Medicare and drug makers. The federal government provided temporary prescription discount cards and offered an additional Medicare Part D plan with annual premiums and deductibles of hundreds of dollars for beneficiaries.If the federal government prioritized reducing patient spending, and could muster the political will, instead of succumbing to industry influence, prescription drug pricing would be capped at the source, and Medicare members would have lower out-of-pocket costs. Subsidizing the cost of prescriptions served as a superficial, short-term response that has subsequently allowed pharmaceutical companies to increase the price of drugs, thus mitigating the intent of federal assistance.

An analysis of Medicare data from 2019 found that Medicare spent $321 more per Advantage enrollee as compared to traditional Medicare, which contributed to an overall increase of about $7 billion in additional spending by the end of that year.Over time, CMS has increased benchmarks for how much capital is necessary to cover Part A and Part B for members, and Advantage plans are receiving higher payments for patients with a higher risk score while these same plans are garnering rebates when they spend less than the established benchmarks. When the Bush Administration conceived the reimbursement structure for Advantage plans, there was a deliberate push towards including provisions that would ensure profitability for the health insurance industry. According to an analysis conducted by the Kaiser Family Foundation, “results indicate that beneficiaries who choose Medicare Advantage have lower Medicare spending – before they enroll in Advantage plans – than similar beneficiaries who remain in traditional Medicare, suggesting that basing payments to plans on the spending of those in traditional Medicare may systematically overestimate expected costs of Medicare Advantage enrollees.”

Neoliberalist practices in various industries hone in on short-term economic practices that may deliver goals temporarily, but eventually falter and cost the public taxpayer and government more than private corporations. With the Medicare Modernization Act, a “conservative” policy dedicated to minimizing the federal budget has cost the Medicare program significantly more than expected, as private health insurance corporations reap growing profits from Advantage members and the government, in the form of CMS reimbursements and rebates.

Health Disparities Created by Advantage

Although Medicare Advantage offers more than traditional Medicare and the individual plans are rated and shared in the form of a quality measurement system, Advantage beneficiaries are suffering from greater health disparities while struggling to understand the true value of additional costs. CMS has constructed and utilized a 5-star rating scale to evaluate health plans on performance, and to provide prospective members with the ability to compare plans with one another. The 5-star scale constructed to asses Advantage plans is comprised of the following  categories: 

1. Access to preventive services
2. Coordination of chronic care and utilization of chronic care services
3. Member satisfaction with the health plan
4. Number of member complaints and difficulties using health services along with member attrition 
5. Quality of call center customer services, ranging from inclusivity to rapid processing.

Advantage plans that receive 4 or 5 stars, generate a significant bonus payment from the federal government, and these payments have been increasing steadily from $3 billion in 2015 and subsequently, nearly quadrupled to $11.6 billion in 2021. Many plans perform exceedingly well, but the impact of the star ratings on root causes of poor health outcomes, such as racial and socioeconomic disparities, have been widely ignored and excluded from payer priorities. 

Researchers at Brown University attempted to elevate this issue by analyzing over 1 million Advantage beneficiaries and re-calculating the star ratings, adjusted for socioeconomic status and race/ethnicity. This study found that top-rated plans had the greatest disparities in health outcomes between low and high socioeconomic status, Black and White members, and Hispanic and White members. Research assessing hospital readmission rates among Medicare enrollees quantifies the stark differences among those with Advantage plans. Black patients with traditional Medicare were 33% more likely to be readmitted within 30 days as compared to their White counterparts, whereas Black patients with Medicare Advantage were 64% more likely to be readmitted as compared to White patients.

Not only has quality of care been an area of concern for Medicare Advantage plans, but cost, one of the most debilitating barriers to healthcare, has surfaced as a challenge for individuals of color. When analyzing the entire sample pool, and by each individual racial category,  more Medicare Advantage beneficiaries report cost-related problems, as compared to traditional Medicare. The Kaiser Family Foundation reported that 15% of traditional Medicare beneficiaries faced cost-related challenges as compared to 19% Advantage enrollees. Segmenting the data into racial categories found that 32% of Black Advantage beneficiaries reported a cost-related problem as compared to 19% of their White counterparts. People of color already suffer tremendously as a result of biases deeply entrenched in the healthcare system, in terms of poor health outcomes and cost barriers. Medicare Advantage has been shown to heighten disparities by facilitating inequitable care models that do not deliver the same value to each person, regardless of race or socioeconomic status.

Concluding Commentary

Medicare Advantage has incredible potential to contain healthcare costs and drive seniors towards greater utilization of preventive health services, but currently poses one of the greatest challenges to cost-effectiveness and equity in the U.S. healthcare system. Medicare, a program once ideated to create equity among all adults over the age of 65 is well on the path to privatization, as well as preferential treatment. When enacting the Medicare Modernization Act, President George W. Bush espoused the benefits of providing senior citizens with more private health insurance plan options and driving down Medicare spending, but the opposite has occurred. 

The proliferation of Medicare Advantage plan options has led to confusion, as vulnerable populations such as the elderly may have lower levels of health literacy and encounter greater difficulties in navigating these options. Unfortunately, we, the authors of this article, have experienced this first-hand with our own elderly relatives, fielding their questions on the benefits of Medicare Advantage versus traditional Medicare and witnessing their difficulty in understanding complex insurance billing. With the limited familiarity of rapidly evolving technology and a range of health conditions, navigating the health insurance market is simply draining and frustrating for many of our nation’s senior citizens.

Champions of Medicare Advantage tout greater health outcomes overall, but that ideology is flawed because the wealthiest seniors, a population that can afford high premiums and deductibles associated with Medicare Advantage, maintain a higher level of health. Advantage affords greater access and quality of care for those privileged by social class and racial category. It is truly an ‘advantage’ for some, to the exclusion of those with little to no socio-political capital to advocate for themselves.

A core concern lies with the star rating system, which is intended to reflect the quality of Advantage health insurance plans and associated healthcare quality, along with beneficiary satisfaction. Star ratings are currently awarded without a deliberate focus on the core drivers of poor healthcare outcomes and experiences, ultimately perpetuating long-term care gaps that may never be reconciled. CMS should incentivize health insurers to promote Advantage plans more equitably among eligible individuals – to address disparities in health outcomes among Advantage beneficiaries and mitigate persistent disparities in health care access and quality, likely to further disenfranchise vulnerable populations and drive higher tertiary care costs. To contain costs and promote the wellbeing of Advantage and traditional Medicare beneficiaries alike, healthcare stakeholders need to advocate for, and funnel future investments into population health improvement measures. Such measures can complement the 5-star quality ratings, to provide broader contextual insights and a more substantive feedback loop for beneficiaries, providers, researchers and policy-makers. 

Nirban Singh is an MPH student at Northeastern University with a passion for investigating the role of health policy in creating equitable outcomes.

Professor Amy Helburn, PhD, MPH of Northeastern University conducts applied health policy research for federal and philanthropic clients.

By KIM BELLARD

Happy New Year!  We’re starting 2022 full of hope and renewed optimism. Oh, wait; not so much. We’re not only still in a pandemic, the Omicron variant is the most infectious one yet.  Daily cases are setting new records. Our hospitals are full again. Our beleaguered healthcare workers – the ones who haven’t already thrown in the towel – are at their breaking points.  Two years in, and we still don’t have enough tests. We’re in the greatest public health crisis in a century, yet our legislators are taking power away from public health officials, and their angry constituents are forcing many of those officials to quit. We have effective vaccines, but millions still refuse to take them. 

The Simpsons – especially, Homer — has the right word for this: D’oh!

Even those who are not Simpsons fans – and I don’t know who these people are – are probably aware of the show. With over 700 episodes and 33 seasons, it is the longest-running American animated series, sitcom, and primetime television series.  The titular head of the family is the hapless, impulse-driven Homer, who is most associated with the expression “D’oh.”

Merriam-Webster defines “Doh” as an interjection “used to express sudden recognition of a foolish blunder or an ironic turn of events.”  One analysis found that if Homer were a real person, his various healthcare experiences over the years would have cost him over $143m, giving him plenty of opportunity for D’oh. 

Got a medical bill that seems outrageously high?  D’oh!  Your insurance won’t cover some procedure that you or a family member needs?  D’oh!  Can’t afford to see a doctor, fill a prescription, or buy insurance? D’oh! Have to wait days, weeks, even months to get a medical appointment?  D’oh! Have to carry your health records around on a CD or paper because your doctor’s/health system’s EHR doesn’t communicate with your other doctors’/health systems’ EHRs?  D’oh!

You have your own stories.  You’ve had your own frustrations.  You may even have your own favorite expression (or expletive) to use when running up against the healthcare system. But I prefer “D’oh,” because, as with Homer Simpson, at the end of the day we have ourselves to blame for the mess we’re in.

There’s another Simpsons clip that may help explain. You can watch the clip below, but, briefly, Homer gets his arm stuck in a vending machine trying to get a free soda. Emergency personnel are summoned, and they literally are about to cut his arm off when an EMS worker realizes that the problem is that Homer has refused to let go of the soda can.  

The question for us is, what is the metaphorical soda can in our healthcare system that we so tenaciously continue to hold onto, even at the risk to our health and lives?

Some might say it is our failure to implement universal healthcare, as almost every other developed country has done. It’s baffling that, even after ACA, we’ve got close to 30 million people without coverage, and there’s no political will to change that. It’s worse than baffling – it’s horrifying – that 12 states still haven’t expanded Medicaid, as ACA allowed/paid for, which would protect their most vulnerable citizens. But, even in states that have expanded Medicaid, affordable coverage is available to everyone, yet not everyone takes it.

Others might say it is our continued reliance on fee-for-service payment, which critics believe encourages overuse. We’ve tried capitation, we’re still trying value-based payment, and yet fee-for-service continues to dominate. But that doesn’t make our healthcare system different than most other countries’ systems. 

Maybe it is that we act as though quality is a given: “my doctor is the best,” “our hospital is just fine for any care,” when, in fact, quality of care varies greatly and it very much matters what care you get and from whom you get it. “Quality” in healthcare is surprisingly amorphous; similar to Justice Potter Stewart’s belief about obscenity: we think we know it when we see it. We don’t. But, again, that’s true in every healthcare system.

A strong argument can be made that the foolish thing we persist in is allowing so many payors to each negotiate their own rates with health care providers. It’s well documented that Americans pay far more for healthcare products and services than anywhere else. We don’t have too many doctors, we don’t have too many hospitals, we don’t get too many procedures or tests, we don’t take too many prescriptions. We just pay way too much each of the times we do any of these.  As Dan Munro, author of Casino Healthcare, likes to say, we don’t need a single payor, we need single pricing.  But, then again, we don’t have that kind of single pricing for anything else – not food, not energy, not water, or any other essential products and services.

And therein, I think, lies our real problem, the soda can to which we persist in holding on to no matter what. America preaches individualism, of the ability for anyone to “make it” here.  We claim to treasure self-reliance and look skeptically at government help (except, of course, Social Security, Medicare, or disaster relief).  

We know we should lead healthier lives, but most of us don’t.  We know we should listen to the experts, including our doctors, but as the current pandemic is proving, too many of us don’t. We know healthcare and health insurance are way too expensive, but we continue to shrug at their costs. So we have an out-of-control healthcare system – and, for similar reasons, exploding deficits, crumbling infrastructure, and climate change that will soon drastically change our existence.

D’oh, indeed.  

The Simpsons is a cartoon.  It’s satire. Homer isn’t going to have to pay that $143m. Homer won’t suffer any consequences past the end of the episode. We’re not so lucky. We have to live with – or die from – the consequences of the foolish blunders we make or the ironic turns of events we find ourselves in, especially when it comes to healthcare

It’s 2022.  Let’s stop accepting the unacceptable.  Here’s what our New Year’s Resolution should be: no more healthcare D’ohs.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.

Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

By CATALYST @ HEALTH 2.0

Nearly a decade has passed since Healthy People 2020 positioned social determinants of health (SDoH) at the forefront of healthcare reform. As defined by the report, SDoH are the “conditions in the environment in which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality of life outcomes.” Examples of social determinants include:

• Resources to meet daily needs (e.g., safe housing and local food markets)
• Educational, economic, and job opportunities
• Community-based resources in support of community living and opportunities for recreational and leisure-time activities
• Transportation

The ability to influence social determinants largely falls outside of the health care system’s reach. Therefore, a key to address opportunities for health involves collaboration between health care and different industries such as education, housing, and transportation. Both the public and private sectors have made significant efforts to bridge the gap between physical, mental, and social care by experimenting with non-traditional partnerships.

The Center for Disease Control and Prevention (CDC) has spearheaded multiple programs with government agencies and community partners to achieve the goals outlined in Healthy People 2020. One of the most notable successes is the Childhood Lead Poisoning Prevention Program, an initiative by the CDC with the Department of Housing & Urban Development and the U.S. Environmental Protection Agency. Through housing rehabilitation, enforcement of housing and health codes, and partnerships with healthcare experts, the program helped Healthy People 2020 exceed their target of reducing blood lead level in children.

Other programs such as the “National Program to Eliminate Diabetes Related Disparities in Vulnerable Populations,” leveraged community partners and resources to increase food security, health literacy, and physical spaces for active living. In one of their projects, the program partnered with community health workers (promotoras) who spoke Spanish to engage with Hispanic/Latino communities where participation to Diabetes Self-Management Education (DSME) was low. The community health workers provided linguistically and culturally-sensitive materials that effectively increased participation in DSME among the targeted population. The outcomes from such initiatives have inspired more health and community organizations to work together to reduce health disparities.

Private health insurers have also joined the movement to influence SDoH as the shift towards value-based care incentivizes them to keep their beneficiaries healthy beyond clinical settings. Kaiser Permanente, which prides itself on helping their beneficiaries achieve total health, will launch their social care network Thrive Local to connect healthcare and social services providers. Thrive Local will be powered by Unite Us, a startup that helps providers refer social services, track outcomes, and collaborate care with community partners. Meanwhile, Blue Cross Blue Shield has invested nearly $40M into Solera Health to integrate social determinants data and resources into healthcare. Solera Health will use the funding to build out a network of digital health and social services providers and reimagine how health plans will pay social service providers. Both insurers are hopeful that the partnerships will promote better health outcomes and create a new care delivery model that effectively address social needs.  

Developers and innovators are encouraged to create technology that can support the integration of SDoH collaborations into healthcare. Those who are interested in this space and have a digital solution should apply to the “Robert Wood Johnson Foundation Social Determinants of Health Innovation Challenge,” which seeks novel technology that helps providers and/or patients connect to health services related to SDoH.

Examples include but are not limited to:

• Digital tools that pull data from non-profit services to assist health systems in serving diverse patient populations on an ongoing basis
• Apps for consumers that provide health information based on their community/location
• Technology that harnesses governmental or open source data to create insights for healthcare providers to evaluate SDoH data and improve population health

In this multi-phase challenge, innovators are asked to submit tech-enabled solutions that account for SDoH. Subject matter experts will evaluate the entries and select the top five teams who will move onto Phase II. The five semi-finalists will be awarded $5,000 each to further develop their application or tool. Then, three finalists will be chosen at the end of Phase II to compete at a live pitch event! They will demo their technology in front of a captivated audience of investors, provider organizations, and members of the media at a prominent health conference. Judges will select the first, second, and third place winners live. Winners will be awarded $40,000 for first place, $25,000 for second place, and $10,000 for third place.

The challenge is open to innovators and companies at any stage of development. If you are interested in applying, the competition is now accepting Phase I applications and the deadline to submit is June 7th, 2019 11:59 PM EDT.

To learn more about the challenge, please visit the website. To sign up for updates on the challenge, please click here.

Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.

By PHUOC LE, MD and SAM APTEKAR

Fifteen years ago, as a medical student, I learned a terrifying lesson about blindly using race-based medicine. I was taking care of Mr. Smith, a thin man in his late 60s, who entered the hospital with severe back pain and a fever. As the student on the hospital team, I spent over an hour interviewing him, asking relevant questions about his medical and social history, the medications he took, and the details of his symptoms. I learned Mr. Smith was a veteran who ran into tough times that left him chronically homeless, uninsured, and suffering from hypertension and diabetes. I performed a complete physical exam, paying particularly close attention to his back. Upon reviewing his blood tests and kidney function, I read the computer’s report: “normal.”

I felt confident as I presented Mr. Smith’s treatment plan to my attending physician: I recommended a CT scan, ibuprofen for pain, blood pressure lowering medication, and an antibiotic. My attending listened quietly, reviewed the labs herself, and then firmly corrected every aspect of my treatment proposal. “His kidney function is NOT normal. What you want to do for him can further damage his kidneys. The lab reported his creatinine as ‘normal’ because it has an algorithm that makes faulty assumptions based on race.” Mr. Smith, according to the medical record, was African American.

I almost harmed Mr. Smith because I hadn’t realized that the exact same creatinine level (the key metric for kidney function) yields two different reports based on whether you’re African American or not. The logic goes that because black people supposedly have higher muscle mass on average, healthy creatinine levels for those who check the “black” box is different from those who check other boxes. Physicians around the country continue to rely on this metric even when the black patient is thin, like Mr. Smith. This example of race-based creatinine levels to determine kidney function is a symptom of race-based medicine in general: (poorly defined) racial categories are often used as proxies to explain discrepancies in health outcomes by race, which is a potentially dangerous analysis. Mr. Smith’s case forced me to consider why race-based medicine is problematic and where our attention as healthcare providers should be directed instead.

What is certain is that health inequities persist along racial lines. African Americans and Hispanics have higher rates of diabetes, hypertension, and heart disease than other groups (Figure 1).[1] American Indians and Alaskan Natives are 2.1 times as likely to be diagnosed with diabetes as white individuals and the prevalence of obesity in this population is higher than any other group. While it would be convenient to attribute these disparities to genetic difference, this is simply not the case.

Using race to predict different health outcomes is problematic for more reasons than one. Let’s start with why it’s bad science and bad medicine. Because racial categories have been socially constructed, the definitions and qualifications for each race are dependent on location and time.

These racial categories have been proven time and time again to mean very little genetically, yet medicine continues to assume that innate biological difference among races explains racial disparities in health. Why would we test race to predict muscle mass to then predict kidney function when instead we can just test muscle mass to predict kidney function? That would avoid crude metrics like race and use more scientifically-justified criteria to predict health outcomes.

The second problem with race-based medicine is that it detracts clinicians from the social determinants of health disparities. If we really want to know why the above statistics hold true, let’s start by looking at insurance rates among these groups (Figures 2-3). Eighty-eight percent of whites have health insurance while only 79% of African Americans and 68% of Hispanics and Native Americans do. One in five Latinos reported not seeking medical care due to a language barrier. Forty-six percent of nonelderly blacks without health insurance report having one or more chronic health condition. High rates of incarceration among communities of color (Figure 4), exposure to environmental toxins, underfunded schools, food deserts, and the daily stress of racial discrimination all play powerful roles in determining health outcomes. Race-based discrimination also enters the hospital. Blacks and Latinos are twice as likely to be refused pain medication than whites for the exact same injury because black and brown patients are perceived to feel less pain or to somehow be more prone to addiction. These social and political factors, not race-based computer algorithms, must be the target of our focus as clinicians.

As healthcare providers, we must focus on the much more complicated ways our country’s healthcare, education, and prison systems discriminately affect health outcomes. Thinking back to my experience with Mr. Smith, my plan should have addressed his homelessness and access to healthcare as causes for his sickness because for him, social factors, policies, and opportunities influenced his health far more than genetics. Mr. Smith’s case taught me a valuable lesson that I continue to believe today: when we see differences in health outcomes along racial lines, our focus should not be directed toward innate biological difference, but toward social inequity. The medical establishment, and we as healthcare providers, have a big role to play in changing this narrative.

Internist, Pediatrician, and Associate Professor at UCSF, Dr. Le is also the co-founder of two health equity organizations, the HEAL Initiative and Arc Health.

[1] The authors understand that the term “Hispanic” is controversial. We have decided to use this term in this instance, however, to be consistent with the categorizations used by national healthcare agencies, such as the CDC. For more discussion about on the term, see here.

By PHUOC LE, MD and SAM APTEKAR

Most will be surprised to learn that American Indians and Alaska Natives represent the only populations in the United States with a legal birthright to health care.[1] Even though Article 25 of the UN’s Universal Declaration of Human Rights declares, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including…medical care and necessary social services,” U.S. federal policy only guarantees this human right to enrolled tribal members. The source of this juridical entitlement is what the United States Supreme Court has defined as the federal trust responsibility.

Between 1787 and 1871, the United States signed nearly 400 treaties with Indian tribes, in which, for the exchange of millions of acres of tribal land, the U.S. government promised in perpetuity to respect their sovereignty and provide benefits, including housing, education, and healthcare. Argued in March 1983, United States v. Mitchell is the most recent Supreme Court case establishing this principle as a matter of law. This week marks the 36-year-anniversary of that seminal case, providing us the opportunity to discuss the federal government’s failure to adequately fund the healthcare institutions that serve American Indians and Alaska Natives despite its legal responsibility to do so.

The current life expectancy for American Indians and Alaska Natives is 73 years, 5.5 years less than that of the general population. American Indians die at higher rates from heart disease, cancer, diabetes, stroke, and kidney disease. When we consider why Native communities suffer from preventable and treatable diseases at disproportionate frequencies, we must first evaluate the inequity in Congressional funding for Indian Health Services (IHS), the national agency within the Department of Health and Human Services that is responsible for providing comprehensive healthcare to the country’s enrolled American Indians and Alaska Natives.

Based on the most recent available data, per capita spending on Indian Health Services is far lower than any other federal health care agency, including Medicare, Medicaid, and the Bureau of Prisons. In 2016, Congress invested$3,337 per capita on Indian health care, compared to $5,000 on prisoners and $12,744 on Medicare beneficiaries. For anyone intent on remedying the perpetuation of chronic health disparities that afflict Native communities, Congress’ stark underfunding of IHS should be prioritized rectification.

According to a report published by the U.S. Commission on Civil Rights, an independent, bipartisan agency established by Congress, “Over the past 300 years, Native Americans have traded hundreds of millions of acres to the federal government in exchange for benefits to guarantee the survival and integrity of their tribes, including health care.” So why does the only population in the United States with a guarantee to healthcare at birth suffer from preventable diseases at grossly disproportionate rates? There is no easy answer to this question as it is both morally and legally reprehensible.

If we, as physicians, wish to see the actualization of the historical promises made by the U.S. government to its American Indian citizens, we must be aware of, and speak up for, the urgent need for increased funding to IHS. To be sure, this is not where the fight ends; more equitable health outcomes will only occur if we also target systemic inequality in housing, education, and income, but it is certainly a starting point we can all rally behind.

[1] There is no universally agreed-upon term for the first peoples of North America. In his influential 1998 essay, “I Am an American Indian, Not a Native American!” South Dakota activist Russel Means denounced “Native American” as a “generic government term used to describe all the indigenous prisoners of the United States.” Other activists, however, have provided differing perspectives. Ultimately, the decision lies with individuals among these communities. However, the authors of this post have selected the imperfect term “American Indian” because of its legal implications; at a 1977 United Nations conference in Geneva, the Native representatives unanimously elected the use of “American Indian,” which now predominates in legal settings.

Internist, Pediatrician, and Associate Professor at UCSF, Dr. Le is also the co-founder of two health equity organizations, the HEAL Initiative and Arc Health.

Sam Aptekar is a recent graduate of UC Berkeley and a current content marketing and blogging affiliate for Arc Health Justice.

This post originally appeared on Arc Health here.

It’s impossible to know exactly what shape healthcare will take for Americans as Congress and President Obama struggle with reform measures in the coming months. But one thing is certain: Those who have limited English proficiency will continue to have more health care services they can understand. Though the U.S. has prohibited discrimination, including language access for limited English proficient persons, since the passage of the Civil Rights Act of 1964, the reality in the healthcare industry is very different. Whether insured or not, those who don’t speak or read English “very well” tend to have care that’s not as good as those who do.  The Agency for Healthcare Research and Quality (AHRQ) reported that in 2005 only 54 percent of Latinos experiencing an injury or illness had timely access to healthcare, compared to 65 percent of whites. And if uninsured, Latinos got care in only 27 percent of cases.

It should be pointed out that “treatment” extends clear through medication, and here also, there’s room for improvement as many pharmacies fail to provide prescription information in a language other than English. A recent study by the Albert Einstein College of Medicine in New York of all 161 pharmacies in the Bronx, N.Y. (a borough with a large Spanish-speaking population) revealed that 31 percent could not provide prescription labels in Spanish. And one pharmacy used translation software that couldn’t translate common prescription terms like “dropperful.” Miscommunications in healthcare can have dire results. A child given a tablespoonful of medication when a dropperful was prescribed could wind up poisoned or worse. And then there’s the simply spoken miscommunications that can be deadly, such as the 13-year-old Phoenix girl whose ruptured appendix was initially mistaken for gastritis because no one could question her Spanish-speaking parents. Her death in 1984 sparked a lawsuit resulting in a $71 million malpractice award against the hospital and physicians involved. Such horror stories simply don’t have to happen if health care professionals take care to make themselves understood — in everything they do, from spoken to written patient materials and prescriptions. The Civil Rights Act of 1964 pointed out that language barriers are a form of discrimination. But it wasn’t until August 2000 when President Clinton signed executive order 13166 to remind federal agencies to “examine the services they provide, identify any need for services to those with limited English proficiency (LEP), and develop and implement a system to provide those services so LEP persons can have meaningful access to them.” The state of California followed the federal mandate with Senate Bill 853. Officially signed in 2003, insurance companies had until January 1, 2009 to comply with Senate Bill. 853. The law requires health, dental and specialty insurers licensed in California to have services, information and materials available to LEP members in a language they can understand. Other states are considering similar legislation. Healthcare organizations that are making real strides in translating materials for non-English speakers are not only fulfilling the laws, they’re fulfilling their mission to improve health. It’s been shown that if people get healthcare information in own language, the care gets better, whether it’s understanding health insurance policies to taking medicine. Chanin Ballance brings a wealth of expertise in language translation services and multicultural communications to viaLanguage. She co-founded viaLanguage in 2000 and served as the Chief Operating Officer prior to her appointment as Chief Executive Officer in 2003. Previously, Chanin co-founded The Language Company, a language and cross-cultural training school and translation service provider.