Assemblyman Victor M. Pichardo - Making Government a Force for Good

Bronx Health REACH continues its series on individuals who have made a significant contribution to not only the Institute for Family Health, but to the African-American, Black and Latino communities in the Bronx where they have been strong activists for needed change. A notable member of this group of change agents is New York Assemblymember Victor M. Pichardo, representing the 86th New York State Assembly District, which includes the University and Morris Heights, Mount Eden, Kingsbridge, Tremont, and Fordham sections of the Bronx.

Assemblyman Victor M. Pichardo became interested in public service following a family tragedy fifteen years ago. The Asemblyman’s cousin, who had been working as a livery cab driver, accidently bumped a motorcycle and the motorcyclist ended up stabbing his cousin to death. The suspect fled to the Dominican Republic. “It seemed like the case to get the guy that killed my cousin had stopped, so Senator Charles Schumer took an interest in the case and flew down to meet the President of the Dominican Republic to request extradition. Unfortunately word got around and the suspect then fled to Belgium. With the assistance of Senator Schumer, Interpol tracked down the suspect and he was later brought back to face justice. From that point on, I understood that government is, and should always be, a force for good.”

Assemblymember Pichardo's start in public service began as an intern for Senator Schumer, and eventually became the Community Outreach Coordinator/Latino Liaison. After taking a position at Mercy College, Pichardo discovered that public service was a better fit, and took a job as the Director of Community Affairs for New York State Senator Gustavo Rivera. In this position he saw the severity of health disparities faced by Bronx residents. “I have heard residents tell me, ‘My daughter is suffering from asthma, and I still have to wait three months to get an appointment,’ while others have confided that they are unable to get affordable cancer screenings and the only time they can get them is when a community health fair has them for free. But now with the Affordable Healthcare Act in place, health care must be provided to communities of all sizes, regardless of geographic and socio economic status, and individuals should receive the same equity of care in a timely matter.”

With the Bronx being ranked 62 out of 62 counties by the Robert Wood Johnson Foundation County Health Rankings & Roadmaps, Assemblyman Pichardo would like to turn around the negative stereotypes most people have about the Bronx. “It should not matter which zip code you were born in, you should be given and afforded the same resources and opportunities as anybody else in terms of jobs, housing, and education. Take the recent incidents of police brutality, which I feel has spiked in the last few years. Government has a responsibility to make sure that a young man of color, regardless of the neighborhood he lives in, be it the Bronx, Staten Island, Louisiana, or Minnesota, should be able to safely walk in his community, and not lose his life for an unfathomable reason.”

He adds, “People who feel more job and housing secure tend to be healthier overall, and their health outcomes tend to be better. We need to create sustainable safe communities with residents having gainful employment and affordable/stable housing. When that happens your mind is focused on taking care of your health, and the health of your family. The flipside is that being stressed out on things like a paycheck that won’t pay the rent and buy sufficient food, much less healthy food negatively affects ones health.”

Last April, when Bronx Health REACH held the #Not62 – The Campaign for A Healthy Bronx! Town Hall, the Assemblyman spoke to attendees after having spent an all-night legislative session in Albany to finalize the budget. He shared with the audience what he and the other Assembly members had been fighting for - a $15 minimum wage in New York State. “That $15 minimum wage means there is more money in the community for residents to purchase healthy fruits and vegetables, which means healthier outcomes, and that would be one of the first steps we can take to move from worst to the best, so the Bronx is no longer 62 out of 62.”

Reducing Obesity: Not Simple But Doable

Photo via k lachshand

Eating these is one way to reduce obesity.

James R. Knickman President & CEO at the New York StateHealth Foundation  asked the million dollar question in his Huffington Post piece, “What's Workingto Reduce Obesity?” In his post Mr. Knickman reveals that researchers from Drexel University studied a range of experiments aimed at reducing obesity, assessing how effective those strategies were. Researchers concluded that measures such as improving sidewalks and banning trans fats had strong impact but other approaches such as restaurants posting nutrition information had very little, to no impact.

So what does work to reduce obesity?

Mr. Knickman believes reducing obesity comes down to the following points:

- Better and more research will provide a better sense of the impact of various strategies reducing obesity in communities

- Different populations require different strategies so research can determine which approaches are most effective for high risk populations

- Seek out the economic and social benefits of interventions

- Success happens when communities and neighborhoods make it easy and affordable to be physically active and eat healthy foods, rather than one method such as banning trans fats

- All these healthy components add up to create “a neighborhood value, a point of pride” and becomes a part of the culture.

Mr. Knickman asks, “What is the best bang for your buck?” Here at the Bronx Health REACH Coalition we have launched the Towards A Healthier Bronx initiative using policy, systems and environmental improvements that increase access to healthy food, healthy beverages and opportunities for physical activity for over 75% of 675,215 residents residing in 12 high need South Bronx zip codes. Many public health campaigns rely heavily on clinical evidence, but fail to research the motivating factors relevant to that audience. To avoid this our campaign emphasizes actionable health behaviors.

Led by the Institute for Family Health, Bronx Health REACH was formed in 1999 to eliminate racial and ethnic disparities in health outcomes in diabetes and heart disease in African American and Latino communities in the southwest Bronx. Since then the Bronx Health REACH coalition has grown to include over 70 community-based organizations, 47 faith-based organizations, and health care providers. Bronx Health REACH serves as a national model of community empowerment demonstrating ways to build healthier communities by promoting healthy life-style behaviors.

The plan behind Towards A Healthier Bronx is:

- Increasing the number of bodegas and restaurants involved in incentive programs offering and promoting affordable healthy foods

- Increasing the number of farm stands making healthy food more affordable and available to the community

- Increasing the number of public and charter elementary schools emphasizing nutrition education and supporting related school policies

Partnering with bodega, deli and restaurant owners by providing them with training and education makes these initiatives not only a healthy benefit for their customers, but an economic benefit for the business owner. Encouraging chefs to attend monthly trainings on healthy food preparation results in offering patrons 2 to 3 healthier menu options. As New York City neighborhood demographics change, the restaurants and bodegas can now more easily adapt to the healthy choices their new customers are seeking resulting in those restaurant and bodega owners seeing more customers come into their stores and restaurants and gaining more revenue.

Mr. Knickman also states, “So if menu labeling isn't working for the target population--as the Drexel research and other studies suggest--we need to find and test other ways to make the healthy choice the easy choice.” Euny C. Lee, Evaluator and Policy Analyst at Bronx Health REACH agrees with Mr. Knickman citing a New York University study, “Calorie Labeling Has Barely Any Effecton Teenagers' or Parents' Food Purchases” which revealed that posting calories for food items at fast food restaurants had no impact on what consumer purchased.

Euny has moderated several focus groups with our faith-based coalition members to determine which types of messages encourage healthy behavior such as healthy eating and physical activity. Findings reveal educating the community about daily calorie intake to be important as most were not aware that you should consume no more than 2000 calories a day to maintain a healthy lifestyle.

Messaging matters as well. Signs and posters promoting a health benefit rather than a scare tactic elicit more positive behavior changes. Interventions have to be customized to a specific demographic/ethnic group so that it is culturally and linguistically understandable and appropriate. Other results include social support such as having a friend or family member who you are accountable to for your actions to reach the desired health goals.

Focus group members felt this ad was not accurate saying the soda bottle should be bigger and would be more effective if other ailments such as diabetes and heart disease that causes stroke were listed.

Focus group members felt the above ad was actually a real advertisement selling juice boxes and a better message would have been the child drinking from a water bottle.

But the question still remains. “What is doable in the fight to reduce obesity?” Bronx Health REACH can point to a few projects. A city wide campaign was created to serve only low-fat and fat-free milk rather than whole milk at New York City public schools. Bronx Health REACH educated policy makers, Coalition members and residents from the community about obesity and the benefits of reduced fat milk. This led to the New York City Public school system adopting the policy and impacting over 1.1 million children in 1,579 schools as well as a model for public schools in 15 other states.

I don't know if the day will ever arrive where the only thing one needs to do is take a miracle pill that sheds those excess pounds without any physical effort while drinking a large vanilla milkshake every day. What I do know is these healthy initiatives together will begin slowing the overweight/obesity epidemic we now face.

New York Hospitals' Charity Care Isn’t So Charitable

New York State’s Indigent Care Pool (ICP) exists to offset the cost of uncompensated care for uninsured and underinsured patients. Annually, nearly $1.2 billion in Medicaid funds are allocated to 201 hospitals statewide to compensate hospitals for the cost of providing care to people that cannot or will not pay their medical bills. In 2007, the state enacted the Hospital Financial Assistance Law (HFAL) to respond to concerns that hospitals were not properly notifying patients of financial assistance and lacked transparency and accountability for how they using public funds. However, a report issued this month by the Community Service Society found that an overwhelming majority of New York hospitals violate the HFAL and continue to impose barriers to financial assistance.

Bronx Health REACH is a longstanding advocate of providing equitable access to care for uninsured and underinsured patients. Part of this effort involves providing clear financial assistance policies to patients through the hospital’s website and the physician referral line. In 2011, New York State Senator Gustavo Rivera and Assemblyman Nelson Castro introduced legislation that would require patients receive information about financial assistance in these ways, as well as prohibit hospitals from steering patients into different care settings. (To read more about this legislation and segregated care, click here.) The passage of this legislation would be a step forward in ensuring that uninsured and underinsured patients receive the financial aid that they need. However, an overarching concern is that the largest amounts of money are going to the hospitals that provide the least amount of care to needy populations, while the safety net institutions shoulder an increased burden with severely limited funds.

The Community Service Society analyzed state department of health data for all New York hospitals and found that the hospitals that approved the largest amount of financial aid applications generally received a smaller amount of funding. For example, Jacobi Medical Center, a public hospital in the Bronx that treats a large proportion of uninsured patients, received $167 in 2010 for each of the 52,702 financial aid applications it approved in 2008. In comparison, Lenox Hill Hospital, a private hospital on the Upper East Side of Manhattan, approved only 130 applications that year and received $84,469 per application. In this current system, the Indigent Care Pool does not reward safety net institutions, which provide significant financial assistance to needy New Yorkers, as they generally receive a lower amount of funding. The report concludes that the extreme variability in the amount of funding received shows that there is a serious need for change in state policy, as well as increased regulation of how these payments are distributed.

The CSS report contains no end of statistics that detail the non-compliance of New York hospitals under HFAL, as well as the inequitable distribution of resources to safety net hospitals. While these reports are critical in order to shed a light on these practices, they should also be a call to action for communities, organizations, and health care advocates. Enormous amounts of money have been paid to treat indigent patients, yet it’s not reaching the people that need it most. (The New York Times wrote an article on this issue and outlined some patient stories, which you can read here.) Without pressure from the communities that these funds are meant to assist, the hospitals may continue to reap the benefits of state funding without providing the assistance it promises. The $1.2 billion per year needs to go to the people that need it most.

Learning Exchange with UK Communities for Health

Bronx Health REACH was selected by the Centers for Disease Control and Prevention to participate in an exchange with representatives from the United Kingdom’s Communities for Health program. The Communities for Health program intends to increase the role of local government in supporting health improvement and reducing health inequalities. Bronx Health REACH hosted visitors from the city of Nottingham, including the director of the health and well being partnership of the Nottingham City Council and a Nottingham city councilwoman, on November 16^th and 17^th.

As a community coalition dedicated to the elimination of racial and ethnic health disparities, Bronx Health REACH targets individuals through programs to promote healthy lifestyle change, as well as works with policymakers and stakeholders to effect policy change. Bronx Health REACH staff put together presentations to highlight programs that work with faith-based organizations, community groups, health care providers, elected officials, and others to improve health outcomes in the Bronx. We also invited our partners to speak about their work with the coalition and how they believe that Bronx Health REACH has impacted the health of the community. On the second day of the visit, we brought our visitors to the south Bronx and had them participate in a number of events. These included a “Can I Still Be Puerto Rican and Eat Healthy?” event at the MARC Academy and Family Center and the annual Thanksgiving dinner put on by the culinary committee at Walker Memorial Baptist Church for Bronx Health REACH’s Faith-Based Outreach Initiative. This annual event showcases the healthy dishes that have come about because of the nutrition training provided by Bronx Health REACH.

Throughout the learning exchange, we had a number of interesting conversations about the state of health care in the U.S. in comparison to the system in England. Because most citizens in the UK have public health insurance through the National Health Service, the UK visitors were struck by the differences in quality of care between publicly and privately insured patients in the U.S. They also repeatedly mentioned how shocked they were by the level of poverty in the south Bronx and, after hearing about the segregated system of care in New York, said they would go back to the UK with a renewed commitment to avert any efforts by the conservative leaning coalition government to introduce any aspect of a U.S. type health care system.

Time and time again the visitors voiced their awe at how much communities, through the efforts of Bronx Health REACH and others, have undertaken to meet their health challenges from the ground up. At the same time, they also voiced their consternation at the lack of a systemic effort to address health inequities, be it at the city, state, or the national levels. However impressed our visitors were with the work that Bronx Health REACH is doing to improve health in the south Bronx area, their lasting impressions of the broken health care system in the U.S. and the pervasive inequity in our country are profound. It shocked them that the richest country in the world could have such glaring poverty and inequity.

For those of us that work in this field, these realizations are nothing new, but it’s an eye-opener when outsiders so easily see the problems in our system. The learning exchange allowed Bronx Health REACH to showcase our efforts around nutrition, fitness, and health inequity in the community, but it also provided an opportunity to think critically about how health in our country stacks up against others. Unfortunately, we learned that we don’t stack up too well. In order for health to improve in underserved communities in a lasting way, policy and systems change must be at the forefront of our efforts. We all have a part to play to improve health outcomes and the Bronx Health REACH coalition will continue to drive change in its community to achieve health equity.

Race/ethnicity, not health insurance, as primary barrier to quality care

As a community-based organization committed to the elimination of health disparities, Bronx Health REACH works closely on access to health care issues in underserved communities. One of our signature issues is advocating against the segregated health care system in New York City, which separates patients into two systems based on their health insurance status. This two-tiered system discriminates on the basis of health insurance, steering patients on Medicaid or with no insurance toward the clinic system while those with private insurance are seen in faculty practices. We have found that public insurance or no insurance can be a barrier to accessing quality care due to the poor follow-up, lack of continuity of care, and long wait times that plague the clinic system. However, a recent study published in the journal Cancer, found that lack of health insurance may not be the primary barrier to proper diagnostic care for minority women.

The objective of the study was to determine the impact of race, ethnicity, and health insurance on follow-ups from breast cancer screenings in Washington, D.C., an area that has high mortality rates from breast cancer compared with national rates. The researchers’ hypothesis when they began the study was that patients with health insurance would have a shorter diagnostic time (defined as the number of days from a suspicious finding from a breast cancer screening to a definitive diagnosis for the patient) than patients without health insurance. However, after analyzing the diagnostic times of over 1500 women, the researchers found that health insurance was not the main determinant in longer wait times. On average, the diagnostic wait times for white, black, and Hispanic women were half a month, 1 month, and 2 months respectively. For white women on government insurance the average diagnostic time was 12 days; however for black women with the same insurance it was 39 days and for Hispanic women it was 70 days. Similar trends occurred when comparing women with private insurance from the three different racial/ethnic groups (16 days for whites; 27 days for black; and 51 days for Hispanics). The huge difference in diagnostic time between the different racial/ethnic groups suggests that health insurance status may not be the primary barrier to care.

This research highlights the alarming disparity in quality health care between minority groups and whites. While having health insurance does mediate this issue somewhat, the fact that women on the same insurance but of a different racial/ethnic background would have such varied waiting times shows that the system does discriminate against minority groups. In this particular case, the women were waiting to hear whether a breast abnormality identified by a clinician was benign or malignant. Depending on the stage of the cancer, a difference in diagnostic time between 12 and 70 days could be a serious impediment to proper treatment and halting the spread of the cancer. Other studies have shown similar disparity in treatment between white and minority patients. One well-known study by Dr. Kevin Schulman looked at the effect that race and gender had on physicians’ recommendations for cardiac catheterization and concluded that African-Americans and women were less likely to receive a referral than whites and men, with black women being the least likely group to get a referral.  Another study conducted by the Department of Veterans Affairs found disparities in health care between black and white veterans across all clinical areas. The study also suggested that disparities in health care delivery between the two groups are contributing to disparities in health outcomes.

This research all points to the conclusion that racial and ethnic disparities in health care access and delivery are a critical problem in our health care system. Through community outreach and education efforts, such as the health disparities education conducted by Bronx Health REACH, community members are becoming more aware of their patient rights and learning how to advocate for proper care. However, policy and system change must take place both in the training of physicians and in how care is delivered in order to affect lasting change.  

Does having health insurance make you happier and healthier?

Does providing health insurance to the poor actually make them healthier? While a critical question in the long-running health care debate, the impact of health insurance on the poor has been difficult to determine as studies comparing the insured versus the uninsured typically have too many variables (income, education, health habits, etc.) to be completely successful. However, a recent study on the impact of Medicaid in Oregon provides the first rigorously controlled look at the costs and benefits of having health insurance.

This study, published by the National Bureau of Economic Research, took advantage of an unusual situation in Oregon, which decided to expand its Medicaid program by selecting 10,000 uninsured people by lottery. This allowed economists to compare those selected by lottery to receive Medicaid with those who had not been picked. Because it is considered unethical for researchers to deny coverage to some people for the benefit of a study, nothing like this had ever been done before.

In short, the findings from the first year are encouraging. The researchers found that when the previously uninsured were given Medicaid they saw doctors more often, felt more financially stable, reported better physical and mental health, and undertook more preventative health measures. For example, Medicaid coverage increased the likelihood of using outpatient care by 35% and of having a regular doctor by 55%. Women on Medicaid were 60% more likely to receive a mammogram than the uninsured group and the likelihood of people having to borrow money or skip other bills to pay for health care decreased by 40%. However, having Medicaid coverage did not reduce the number of emergency room visits and increased utilization of health care services by the insured added up to an extra 25% in annual medical expenditures, making cost still a significant factor.

With the debate on the expansion of public insurance raging, this study is expected to be a strong argument for insuring the poor. However, feeling healthier doesn’t necessarily mean that people are healthier. The study also didn’t assess the quality of care for those on Medicaid, which is a frequent criticism of public insurance. The second phase of the study will attempt to answer at least one of these questions by measuring the health effects of having Medicaid versus being uninsured. The researchers interviewed 12,000 people (6,000 from each category) and measured variables like blood pressure, cholesterol, and weight. Those results will be released once they have been analyzed.

Insuring the poor is a critical component to reducing the chronic disease burden and eliminating health disparity. Relying on “safety net” hospitals, free clinics, and charity care is not a sustainable option, nor a preferable one. However, expanding public insurance on its own is not enough. Without improving the quality of care of those on Medicaid or raising reimbursement rates so that more doctors accept it, the cycle of poor health outcomes for underserved populations will continue. As this study shows, if people are offered the option to live a healthier life they take it. This should be proof enough.

To read the entire study, click here.