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.  

Take Action and Protect Healthier School Lunches!

Over 31 million children receive lunch through the National School Lunch Program. In New York City alone, public school kitchens serve 860,000 meals each day and service 1.1 million kids. School food is a critical piece in keeping children fed and alert throughout the school day, but it also provides a key opportunity to get children eating healthy. The federal government’s Healthy Hunger-Free Kids Act of 2010 authorizes funding and sets policy for the U.S. Department of Agriculture’s core child nutrition program. Under this legislation, the USDA has proposed nutrition guidelines to improve school lunches and breakfasts by including more fruits, vegetables, whole grains, and low-fat milk, as well as cooking with less salt and fat. Despite support from tens of thousands of parents and organizations, some members of Congress are trying to stop these guidelines from being finalized. 

According to the most recent estimates by the U.S. Census Bureau, over 20 percent of America’s children live in poverty. In New York City, the number of children living in poverty ranges from 25 to 33 percent depending on age group. Overall, 76% of elementary and middle school children in NYC receive free lunch and in some neighborhoods that number is much higher. (In the South Bronx, almost 95% of elementary and middle school children receive free lunch). For many of these children, school meals provide one of the few available opportunities for a nutritious meal. The food deserts in which many of these children live only compound the problem by providing few options to access healthy, affordable food. By insuring that school food follows common-sense nutrition guidelines, these children can eat healthy twice a day, which will lower risk factors associated with childhood obesity. Other national efforts to fight childhood obesity, including the Partnership for a Healthier America’s recent initiative to bring healthy, affordable food to 10 million people over the next five years, are crucial. However, the USDA guidelines are a critical weapon in the fight to combat childhood obesity in high need, vulnerable communities and they must be protected.

The House of Representatives has already included a rider on its agriculture spending bill to urge USDA to start over and propose a new set of school meal standards. The Senate will vote on its own agriculture appropriations bill on September 7^th. To keep healthy school lunches, please send an email to both of your Senators asking them to support USDA’s efforts to improve school meals. Go to https://secure2.convio.net/cspi/site/Advocacy?cmd=display&page=UserAction&id=1251 and take action!

Preaching Healthy Living from the Pulpit

This week The New York Times published a story highlighting the efforts of pastors in the Mississippi Delta to get their congregations to eat healthier. In a state with the second highest adult obesity rate and ranking dead last in life expectancy, the Delta is especially hard hit. Fried and heavily-salted foods dominate the culinary scene and, if there are greens, they are often boiled with ham hocks. Pastors, alarmed by the health of their congregants, began to promote healthier food options at church events and encourage physical activity. Like many attempts to change long-standing traditions, these efforts were initially met with skepticism, if not outright resistance, but over the years more Delta churches and their congregations have begun to change the way they think about food.

Preaching healthy living from the pulpit is not unique to the Mississippi Delta. For the past decade, Bronx Health REACH’s Faith-Based Outreach Initiative has been working with faith-based leaders to incorporate health messages into church activities and provide programming around nutrition and fitness, diabetes prevention and management, and health disparities. Currently, Bronx Health REACH works with 47 churches throughout the Bronx and upper Manhattan. These programs include a Culinary Initiative, which works with church culinary committee members to serve healthier meals at church events, and Fine, Fit, and Fabulous, which teaches nutrition and fitness within a spiritual context. These programs and others have contributed to both behavior change and weight loss in participating congregants.

Faith-based institutions are key partners in the effort to counteract obesity and prevent diabetes. Pastors, as leaders in their community, have a unique ability to speak to their congregations about the importance of eating healthy and exercising. Because churches engage in many community events, as well as provide meals to their congregants, they are able to influence what kind of food is served and encourage churchgoers to use healthy cooking methods at home. In a similar way, exercise and/or diabetes management programs conducted in a church setting or with spiritual elements provide a familiar background or context to people starting a new activity. The built-in support of the church community is a crucial part of encouraging congregants to continue to eat healthy and to follow exercise regimens.

Battling the obesity epidemic in our communities requires a multi-pronged approach and investment from all parts of the community. Faith-based institutions and their leaders are a critical piece in bringing the message of healthy living to community members. The example that the pastors in the Mississippi Delta and those in Bronx Health REACH’s Faith-Based Outreach Initiative have set is one that can and should be followed in faith communities throughout the country.

Farm to Table: Supporting CSAs in Our Community

Not too long ago having access to farm fresh produce in urban areas meant driving upstate and picking apples or paying high prices at gourmet grocery stores. But the recent advent of Community Supported Agriculture (CSA) programs, which have been popping up throughout the Bronx and other underserved communities, are now bringing the farm to the city. CSAs give communities direct access to high quality, fresh produce grown by local farmers, who bring their wares to a designated drop-off site once a week for a reasonable cost. Participants buy a farm share, usually enough for a family of four, and can often use food stamps or pay on a sliding scale depending on income. At last count, there were approximately 12,000 CSAs in the U.S. and 350 in New York State alone.

The growing importance of CSAs in urban areas and food deserts (discussed in a recent blog post here) is underlined by the introduction of the Community Supported Agriculture Promotion Act by Senators Gillibrand, Leahy, Sanders, and Tester. This proposed legislation would create a competitive grant program within the U.S. Department of Agriculture (USDA), which would award federal funds to support new and current CSA farmers, develop innovative methods of delivery and distribution, and promote participation through outreach and education activities. The program would give preference to CSAs that expand their reach into food deserts or low-income communities.

This legislation is good news for fresh food advocates, who have been working to connect farmers with community members in underserved areas. Bronx Health REACH has been an active partner in supporting CSAs throughout the community and provided funding to the NYC Coalition Against Hunger to start a Bronx-based CSA that brings produce from Fresh Radish Farm in Goshen, NY to the Seventh Day Adventist Temple on the Grand Concourse in the Bronx. Kelly Moltzen, Bronx Health REACH’s nutrition coordinator, is a member of the South Bronx CSA and recently visited Nolasco Farms in Sussex County, New Jersey where she learned about the 50 kinds of produce grown on the farm (see photo below). If you’re interested in joining a CSA or starting one in your neighborhood, the organization Just Food keeps a running list of CSAs in New York City and provides information to people interested in starting a program.

The Community Supported Agriculture Promotion Act will give crucial support to CSAs throughout the country as they connect underserved communities with local farms. Farm to table is not just a restaurant fad, but a true movement that is being recognized by our legislators. Let’s keep the momentum going!