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Friday May 15, 2015

The Heckler Report: Reflecting on its beginnings and 30 years of progress

By Louis W. Sullivan, MD


I recently had the opportunity to participate in DHHS’ celebration recognizing the 30th anniversary of the release of what’s now referred to as “The Heckler Report.” The report was developed thanks to Secretary Margaret Heckler who recognized the “sad and significant fact… [that] there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation’s population as a whole.” Secretary Heckler created the national platform that made the issue of minority health disparities a national issue – but I’d like to share a little of the history that led her to create the “Heckler Report” which has shaped minority health policy for the last 30 years.

Health Equity Summit on Capitol Hill, April 27, 2015Health Equity Summit(left to right): Dr. Satcher, Dr. Sullivan, Dr. Gracia, Dr. Pinn, Mr. Stokes

Walter Bowie (Dean, Tuskegee), Ralph Cazort, MD (Dean, Meharry Medical School), Anthony Rachal (Vice President, Xavier University) and I (Morehouse School of Medicine) founded the Association of Minority Health Professions Schools (AMHPS) in 1977. These four individuals came together with the purpose of working together to develop and promote programs that were (and remain) important to improving minority health status.

We were soon joined by the other health professions schools from the HBCUs (Drew, Florida A&M, Hampton, Howard, and Texas Southern). AMHPS now included colleges of medicine, dentistry, pharmacy and veterinary medicine. The common thread that bound us was our interest in creating more African-American health professionals in these fields. We soon added Latino, Hispanic American and Native American programs to our priorities.

“there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation’s population as a whole.”

Secretary Margaret Heckler

In the early 1980s, we commissioned a study that was led by Dr. Ruth Hanft. The study entitled “Blacks and the Health Professions in the 1980s: A National Crisis and A Time for Action” was a concise report that clearly showed the shortage of minorities in the key medical professions. The health status of Blacks was worse than Whites and we needed greater support in order for that to change. We wanted to make this issue a national priority.

In March 1983, Al Haynes (Charles Drew), David Satcher (Meharry), Walter Bowie (Tuskegee) and I met with Secretary Heckler to inform her about the AMHPS study’s key findings. She was very positive and agreed to review the study closely and get back to us soon. As we left the meeting, we had mixed feelings because although we were well received, we weren’t sure if she really meant it.

But a month later, she let us know that she was setting up a Secretarial Taskforce lead by Dr. Thomas Malone, Deputy Director of the National Institutes of Health, and Dr. Katrina Johnson. Dr. Robert Graham (first administrator of HRSA) was a prominent member of the Taskforce. We were heartened by this development. And two years later in August 1985, Secretary Heckler released the “Report of the Secretary’s Taskforce on Black & Minority Health” that both affirmed our report and extended far beyond it.

Based on the report’s recommendations, DHHS’ Office of Minority Health was created by Secretary Heckler within a year and Dr. Herbert W. Nickens was appointed as the office’s first director. Creating OMH got a lot of attention and helped to set the tone. It began a cascade of Federal-level activities that focused the nation on minority health.

The Heckler ReportIn 1990, during my tenure as U.S. Secretary of Health and Human Services, I created the Office of Minority Health at NIH which first evolved into the Center for Minority Health and Health Disparities, then in 2010 with Congressional legislation, became the National Institute on Minority Health and Health Disparities (NIMHD).

And there are many other examples of the growing prominence of minority health, including the two seminal reports published by the Sullivan Commission and the Institute of Medicine (IOM) in 2004. We can’t ignore the disparities that still exist – such as the low percent of African American scientists who have received NIH research grants – but much has improved.

The Heckler Report was a significant historic touch point for the nation. That’s why it’s so appropriate that DHHS is celebrating its 30th anniversary. Whenever I see Margaret, she always reminds me that the AMHPS report and our meeting focused her on the issue of health equity. It’s good to be a part of the history that made this issue a national priority. With today’s U.S. demographics, these long-standing and recalcitrant disparities have become everyone’s issue, and not just a minority issue.

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Wednesday April 15, 2015

North Carolina Expands Commitment to Diversity in Healthcare

By Dr. Peggy Valentine, Dean, School of Health Services, Winston-Salem State University
and Jacqueline R. Wynn, MPH, Associate Director, NC AHEC Program, President Elect, National AHEC Organization


Spring offers us an opportunity for new beginnings and in North Carolina, we’re excited to be renewing our efforts to transform the health professions and reduce health disparities. In late March, we proudly brought together twenty-two leaders from twenty higher education institutions, state and local governments, to commit to the North Carolina Alliance for Health Professions Diversity (The North Carolina Alliance) at a MOU signing ceremony at Winston-Salem State University (WSSU). Many of us have worked together since 2008 but now, we are formally standing together to reduce disparities in health status and healthcare by creating a diverse healthcare workforce that’s proficient in cross-racial and cross-cultural interactions.

NC Alliance MOU signing

Serendipitous Beginnings

The North Carolina Alliance is unique in many ways and it started with our serendipitous beginning! In 2008, the NC AHEC and WSSU were working on two separate diversity health events and when we learned of each other’s events, we knew we needed to merge them. Around the same time, Dr. Peggy Valentine noticed the work of the Florida Alliance for Health Professions and had a staffer attend one of their meetings to learn and bring their best practices to North Carolina. We held the first North Carolina Health Professions Diversity Conference on March 31-April 1, 2008 in Greensboro, North Carolina where over 150 health professionals, educators, policy makers and legislators attended.

Due to the conference’s success, we were eager to form a steering committee with representatives from various health professions schools, the community college system and local health organizations. At that time, there were a number of disparate organizations focused on diversity workforce issues but no state-wide programs tackling the issue. But thanks to Tom Bacon (NC AHEC), Jacqueline Wynn (NC AHEC) and Dr. Valentine (WSSU), the foundation of the NC Alliance was set. Who knew that seven years later, we’d be working together to make our alliance stronger than ever!

What is at Stake in North Carolina

North Carolina is among the most diverse states in the nation when it comes to race and ethnicity, but minorities only make up a small percentage of North Carolinians employed in the state’s healthcare careers. In a recent NPR interview, Dr. Valentine pointed out that minority representation is 10 percent or less when it comes to those employed as pharmacists and dentists -- so without a concerted effort, North Carolina’s healthcare workforce will not get even close to reflecting the demographics of its population.

North Carolina’s Diversity & Healthcare Statistics: At a Glance

  • North Carolina ranks ninth in respect to percent of African-Americans at 22 percent, Hispanics at 8.9 percent and American Indian/Alaska Natives at 1.6 percent.
  • But in North Carolina, minorities number only one of six health professionals.
  • Licensed practice nurses (LPNs) and primary care providers are the two professions with diversity comparable to the statewide population (around 30 percent are non-white).
  • Nearly four out of five minority health care providers are located in metropolitan counties, thus emphasizing the need to bolster rural health care access.
  • The Health Resource and Services Administration has designated 134 primary care health professional shortage areas (HPSAs) statewide, which encompass a population of over 1.2 million residents.
  • Projections anticipate the need for 184 additional primary care providers to be added to the state’s workforce in order to address the shortage designation.

NC AllianceIn North Carolina, we are very lucky to have one of the nation’s workforce analysis centers – the Cecil G. Sheps Center for Health Services Research (Sheps Center) at the University of North Carolina at Chapel Hill – to rely on for the latest workforce data. This research informs our members on the current status of North Carolina’s healthcare workforce and will allow us to create more data-driven outcomes.

We want our North Carolina Alliance activities to encompass everything from pipeline programs for middle and high school students, to college and graduate school preparation, to practice and retention strategies for practicing health professionals. This comprehensive approach will foster an interest in the health professions and retention of the practitioners through mentorship once they have entered the workforce.

Some of our institution and individual members focus their work deep in the education pipeline because many young students (and their parents) do not know that the health professions require a strong background in science and mathematics – and they are unaware of the variety of healthcare fields. Sometimes young students become aware of the health careers because of a family member’s illness or an accident but otherwise, how can a young person learn about – and choose to be – a health professional? How do they learn what it takes to become a physical therapist, pharmacist, nurse, doctor, or dentist? How would they know that doing well in math and science in middle school will establish good habits and knowledge that will give them options in the future?

For all of these reasons, members of the North Carolina Alliance are already reaching out to middle and high-school students and guidance counselors to provide advice and develop plans for their careers. We also have to a number of initiatives including summer enrichment programs for students and faculty, and mentors for aspiring healthcare professionals and those working on research projects and funding initiatives. And of course, supporting practitioners once they are in the field is just as important as training them. There are too many instances where people don’t stay in the healthcare field due to lack on financial and community support.

NC Alliance founders with Dr. Louis SullivanAnother unique feature of The North Carolina Alliance is our monthly in-person meetings. Twenty or more of us meet monthly. Each meeting is hosted on one of partner’s campuses. Early on, we realized that we really liked working together and learning about each other’s programs first-hand. Our face-to-face meetings create the energy and synergy we need to support our work. We believe in consensus-driven action. Everyone is heard, everyone is equal.

Finally, our partnership is unique because our members are so diverse. During the official ceremony on March 27, senior representatives from 20 colleges, universities, state and local organizations and agencies, and The Sullivan Alliance signed the Memorandum of Understanding. We were thrilled that the North Carolina Office of Minority Health and Health Disparities became our most recent partner. Their involvement underscores the state government’s commitment to diversifying our health professions.

It will take all of us working together to reach the ideal of having our North Carolinian health workforce mirror our population. That’s why our next conference (co-hosted by North Carolina Alliance, NC AHEC, and WSSU) is entitled “Joining Forces to Diversify the Health Professions.” Come and join us on August 27 and 28, 2015 at the Grandover Hotel in Greensboro, North Carolina. Together, we can reduce disparities in health status and healthcare by creating a diverse healthcare workforce. The future looks bright!

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Sunday March 15, 2015

Progress on identifying health disparities in Caribbean and U.S. populations: A Q&A with E. Nigel Harris, MD, Vice Chancellor, UWI


Nigel HarrisIn February 2015, the steering committee for the U.S.-Caribbean Alliance for Health Disparities Research (USCAHDR) gathered in snowy Alexandria, Virginia to hold its annual meeting. The Sullivan Alliance’s Communications Director Samantha Edwards sat down with Dr. Nigel Harris, the Vice Chancellor of the University of the West Indies, to discuss the progress the partnership has made in its first four (of five) years. Dr. Harris has been the USCAHDR’s principal investigator since the inception of the project.

One of the main goals of the USCAHDR partnership is to lessen knowledge gaps in health disparities between English-speaking American and Caribbean populations of African descent. What have you learned over the last 4 years? Have you made any interesting findings?

Well, what excites me is that this is an area of research that’s not had much attention. Over the last four years, there’s much that we have learned – but we’ve also learned that there are more questions than answers. For instance, one of the more exciting pieces of research is that we’ve looked at mortality trends and found that Caribbean populations have fared less well than those of African descent in the United States. There are also huge differences depending on which Caribbean nation you look at. For instance, French-speaking nations are doing better than the English-speaking ones. There is not much research comparing one island to another – and even less comparing the Caribbean to the U.S., hence this work is path-breaking.

One area of research that has opened up is looking at how immigrants have fared in comparison to those populations left behind in the Caribbean. Some studies compare UK immigrants to the majority of the UK population. Few [studies] compare the population they’ve left back in the Caribbean. The same research needs to be done in the U.S. because there are much larger Caribbean populations in the U.S. and Canada.

How do you think this project has advanced the global health disparities agenda?

It’s given us a window into the existence of health disparities between American and Caribbean populations. We now have the evidence that these disparities exist. We know that within the Caribbean there are disparities, but we would not have guessed how large these might be until now.

How is the project advancing the professional development of U.S. and Caribbean researchers and scientists?

First of all, this project has provided new and exciting avenues of research that had not previously been explored comprehensively. And secondly, a number of junior investigators have been supported to do the sort of work that’s potentially ground-breaking – and can be the basis for their career development.

The project also provides a platform to expand collaboration between U.S. and Caribbean scientists.

I understand that The Sullivan Alliance made it possible for your Caribbean colleagues to access and analyze a lot of U.S. research data. What new data do you find most interesting?

I think we’ve been enabled access to a comprehensive array of publications. For example, for research related to diabetes and cardiovascular disease, we’ve been able to access many new journal papers that are not readily available in the Caribbean and select the best data.

How do you hope that this project will continue and expand this year?

There is a considerable amount of work that needs to be done based on what we’ve seen so far. We still need to complete reviews of some disorders, such as depression, stoke and cardiovascular disease. We have seen some exciting differences with respect to trends but we now need to drill down into the causes of those differences.

We also want to find fora in which we can present some of this data since some of our findings could have huge policy implications with respect to healthcare for communities in the Caribbean, as well as for providers and policy officials in the U.S. We need opportunities to tell our story to key players in these communities.

How do you think that future researchers will use this new data?

First of all, this study opens a multitude of new questions and avenues for research. It’s not simply differences between U.S. and Caribbean populations, but also looking at how immigrant populations fare…looking for factors for the differences that one sees – and interventions that might be embarked upon to reduce the disparities observed.

What challenges has the project had to overcome? How will those challenges influence future partnerships such as this?

One challenge was accessing data from the vantage point of the Caribbean, so having that access is a win. The other is finding sufficient numbers of partners in the U.S. – and that’s probably linked to funding. But with more funding, I think more partners will come on board. We are actively pursuing publication of our research and that should also attract more investigators. The first peer-reviewed publication is available online as Open Access.

What are your best memories of this project so far?

By far and away, it is the preliminary findings – some of which were unexpected. I believe that they will have huge implications to the directions in which health policy and healthcare will need to take in the short, medium and long-term future. This was not an exercise in gathering knowledge for knowledge’s sake, but one in which there’s likely to be many practical benefits.

Is there anything else you’d like to say about the USCAHDR partnership?

The Sullivan Alliance has enabled us to access resources and avenues of exploration that would not have been possible had this partnership not occurred. We are grateful for Dr. Sullivan’s influence in the health policy community in the U.S. – as well as his access to leaders in the funding community – that have provided us the wherewithal to support the work we have done – and offer the opportunity for additional studies to sustain this important effort.

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Sunday February 15, 2015

The State of Politics, Education, and Health Disparities in 2015

By Ronny B. Lancaster


President Obama delivered his sixth State of the Union address on January 20th and declared: “Our economy is growing and creating jobs at the fastest pace since 1999,…more of our kids are graduating than ever before, [and] more of our people are insured than ever before…. The shadow of crisis has past and the state of our union is strong.” As I listened to the speech, I wondered if the President would acknowledge our nation’s educational and health disparities – and suggest concrete ways to create equity for our low-income and minority communities.

The President discussed the nation’s economy, environment, energy, defense, and foreign policy – but his boldest idea was to make two years of community college free for students with good grades. Clearly, making higher education more affordable will bring more minority and low-income students further through the education pipeline. And hopefully, with two additional years of education, they will strive towards higher-income careers. In fact, there are many accredited Associate’s degrees offered by community colleges that lead to well-paid jobs in the health professions.

On February 2nd, the President released his budget recommendations for fiscal year 2016. It is dramatically different from the first four years of his tenure. Gone is his cautious attitude towards funding the government. He seems to dismiss notions of continued austerity, citing the rebounding economy. Among the issues receiving more attention in this budget than in previous years are minority health and efforts to eliminate health disparities.

The President suggests that programs and agencies that prioritize strengthening both primary care and diversity among health providers are important investments. However, basically busting the budget caps, the new budget was met on Capitol Hill with extreme skepticism by the House of Representatives, which continues under Republican rule, and the Senate, which is under new Republican leadership. We will need to watch closely as Congress determines what its budget priorities will be.

In addition to the challenge of finding common ground with our Republican-led Congress, the President will need to tackle flux in his Administration since typically, the last two years of any President’s second term see turnover among top Administration officials.

For instance, it is not all surprising to see that Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services (CMS), is choosing to leave her position at the end of February. She completed a controversial, yet ultimately successful, enrollment period of the exchanges for the Affordable Care Act (ACA, or Obamacare) in March 2014, and she will complete the second enrollment phase today (February 15, 2015). It is noteworthy that she was able to roll out the exchanges, without material incident, while maintaining good working relationships with members of Congress, on both sides of the aisle. After she departs, it will be interesting to see if CMS/HHS leadership focus on bringing more of our minority populations – especially Latino and Hispanics who represent one-third of our uninsured – into the exchanges during the 2015/2016 enrollment period.

As we approach the last two years of the Obama Administration, it is unclear how much progress we will make in our collective efforts to address excess morbidity and premature mortality. The President will continue his fight to preserve signal accomplishments such as the ACA even as the Congress, with Republican majorities in the House and Senate work to develop an alternative health insurance plan. He must also aggressively propose new “practical, not partisan” programs that reduce America’s economic, educational and health disparities. Let us hope that one of the areas of common agreement is to preserve and strengthen programs and activities aimed at increasing equity for all Americans.

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Thursday January 15, 2015

Will dental therapists “change the world” (of U.S. dental care) in 2015?

By David Jordan, Project Director, Community Catalyst


David JordanChange is hard. Change takes time. Change is worth fighting for especially when it relates to improving access to oral health care. Faced with an oral health crisis, a decade ago the Alaska Native Tribal Health Consortium (ANTHC) turned to a nearly century-old dental provider model to provide care to their underserved residents. Yet, rather than being championed for employing an innovative and cost-effective approach to address their dental crises, the ANTHC was sued by the American Dental Association. The ANTHC prevailed and as a result, introduced a proven, culturally-competent and patient-centered approach to delivering dental care in the United States. Today, dental therapists are helping 40,000 previously unserved people get care where they live, when they need it.

The innovative approach adopted by ANTHC has become the most disruptive policy solution offered in oral health policy in a generation. As a result of Alaska’s example, Minnesota authorized dental therapists to provide routine and preventive care to the state’s underserved residents. Now, over a dozen states and tribal organizations are pursuing policy change to authorize dental therapists.

After nearly a decade in existence in the United States, the movement to establish the practice of dental therapy is gaining significant momentum despite the strong and well-financed opposition from the American Dental Association. In 2014, we saw great progress:

  • ANTHC celebrated 10 years of dental therapy and dental therapists increasing access to over 40,000 Alaska Natives
  • The Minnesota Department of Health issued a report highlighting that dental therapists that have practiced in Minnesota since 2011 and have expanded access to care, reduced wait times for rural patients, and can potentially reduce hospital ER visits for dental problems. They’ve also improved how dental teams function and as result are making care better for patients.
  • Maine passed legislation to establish the practice of dental therapists
  • The Washington Post editorialized in support of dental therapists
  • The New York Times featuring dental therapists in Social Fixes Column and then a month later noting that dental therapists are “changing the world.”
  • The Albuquerque Journal endorsed using dental therapists to address New Mexico’s unmet health needs.

As we start 2015, over half a dozen states are pursuing legislation to expand access to dental care by adding dental therapists to the dental team.

Building Momentum for Mid-Level Dental Providers

In New Mexico, which nearly established dental therapists last year, we’re seeing public health leadership such as Secretary of Health and Human Services Dr. Alfred Vigil highlighting the need for better care.

The reason there is so much momentum is the growing body of evidence highlighting the efficacy of the model in providing care to vulnerable populations and the significant unmet oral health needs in the nation, for example:

  • More than 181 million Americans go without regular dental visits
  • More than four out of ten children go without regular dental care
  • 51 percent of children on Medicaid did not receive any dental care in 2011, and
  • 45 million people live in areas where they can’t get dental care – and millions more can’t afford it

Now policymakers and the media are recognizing that dental therapists are part of the solution because the evidence that mid-level dental providers increase access to care and provide care at the same level of dentists is undisputed – with more than 1,100 articles showing that dental therapists increase access to quality, safe care.

Even the ADA’s own study found that “[a] variety of studies indicate that appropriately trained midlevel providers are capable of providing high quality services.” The same report noted that dental teams with mid-level providers were more successful at providing services to populations with untreated decay than dental teams with dentists alone.

Thankfully, state legislatures across the country are poised to make mid-level providers part of the solution to our lack of affordable dental care. We expect more to be launched this year. We also expect more states to authorize mid-level dental providers because, like Maine in 2014, policymakers will recognize how essential dental health is to maintaining overall health in their communities. Change is imminent.

Community CatalystCommunity Catalyst is a national, non-profit consumer advocacy organization founded in 1998 with the belief that affordable quality health care should be accessible to everyone. We work in partnership with national, state and local organizations, policymakers, and philanthropic foundations to ensure consumer interests are represented wherever important decisions about health and the health system are made: in communities, courtrooms, statehouses and on Capitol Hill. For more information, visit www.communitycatalyst.org.

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