For 110 years, the National Medical Association [NMA] has been an unwavering voice for parity in the delivery of health care in the United States. As we all know, the struggle for parity continues, and more and more Americans are becoming engaged in the discussion.

The current debate about disparities in health care seems to pivot around the following: are disparities in care dependent on who people are [race and ethnicity], or where people go to get their care [access and quality]?

The framing of that question concerns us greatly for one simple reason. Disparities in health care are unacceptable no matter what the causes. Receiving the highest quality care when you reside in the world’s leading healthcare innovator should, therefore, become the ‘coin of the realm’, no matter who you are, or where you go to receive care.
Simply put - society loses too much when some are more equal than others.

The NMA remains committed to doing whatever we can, strategically and tactically, to bring about lasting system change in the access to and delivery of the highest quality care to all Americans. Given that the patients served by our membership are among the most vulnerable, we will continue to pay close attention to the issues affecting their welfare.

The following is a summation of the most pressing of these issues. Please stay tuned to the site for periodic updates.

Eliminating Healthcare Disparities

Ultimately, this issue impacts and is impacted by all the issues we will list behind it, and should therefore be considered an umbrella issue.

Proposals abound in the medical literature about how to fix America’s healthcare crises. More urgently however, the popular press is becoming more and more involved in the healthcare debate. Perhaps this is a signal that society in general is becoming more interested in these issues. The disparities question, in particular, is getting a lot of attention, but in recent times the debate has probably generated more heat than it sheds light on what we can do to solve the problem.

The NMA takes the position that any solution-oriented national health policy to eliminate [or at least reduce] disparities must, at a minimum, address the following basic questions:

· Can African Americans and other underserved minorities find and have real access to equal high quality health care when they need it?
· Will physicians of African descent and other ethnic and minority groups be available to provide high quality health care to their communities?
· How will America’s healthcare infrastructure support and foster improvement of the health status of African Americans and other underserved minorities?  · What primary issues must be addressed to ensure that America’s healthcare delivery system provides the highest quality care to all its citizens?

In the past, we have taken positions on various strategies and programs for accomplishing the aforementioned. We remain committed to some of those endorsements, including the implementation of the recommendations of the landmark Institute of Medicine (IOM) report, Unequal Treatment. This report, among other salient conclusions, echoed (with data) the NMA’s century-old message that the unintended consequences of racism persist in the delivery of health care in America. The release of more recent data (including studies reported by the American Enterprise Institute and the New England Journal of Medicine) has since provided more ‘food for thought’. Be that as it may, we remain convinced that long-lasting solutions to this crisis will require ongoing conversation and a global perspective on where the fault lines are in the delivery of American health care.

Increasing the Number of Minority Health Professionals

One of the most important conclusions of Unequal Treatment is that there is a need for more “culturally competent” health professionals. It is well established that minority physicians, for example, are much more likely to serve minority patients. We also know that this increases the likelihood of favorable health outcomes. The more minorities recruited into the health professions, the greater the chances of serving more patients in minority groups; which is where the federal government can and should play a vital facilitating role. The current federal budget for training minority applicants in the health professions must be increased. The NMA is convinced that “pipeline” programs aimed at producing significantly more physicians from minority groups, must have the full financial commitment of the federal government.

This current budget cycle [FY 2007] has presented ample cause for consternation in this regard, and we have already expressed our concern during recent congressional visits. We will continue to collaborate with all like-minded parties to move this issue in the desired direction.

Data Collection

Another critical recommendation of Unequal Treatment was the collection of relevant demographic data to determine the health indicators that show an upward trend among minority patients from year to year. There remains an overwhelming need for uniform methods for collecting these various categories of healthcare data. There is also a corresponding need for these data to mean the same thing across scientific disciplines, and to mean the same thing from state to state, and from region to region. Unless we commit to having this objective encapsulated in federal legislation and thus applicable nationwide, we will continue to be faced with initiatives such as Proposition 54 in California in 2003. This initiative sought to prohibit the collection of such data across California’s state and local governments.  Thankfully, Prop 54 was defeated at the polls, but the concern remains that we will not have the tools required to execute the most effective programs structured to eliminate health disparities.

Medical Liability and Malpractice Insurance

An increasing number of America’s doctors are being driven out of business because they cannot afford their malpractice insurance premiums. Worse yet, some of the major liability insurers have left the market, so that coverage is not readily available even to some doctors who can afford to pay the premiums. For example, obstetricians in several markets are now forced to pay over $100,000 a year for malpractice coverage. The result is that doctors are retiring earlier than they would otherwise have, scaling down their practices (obstetricians refusing to deliver babies for example), or relocating to states where they can afford their liability coverage. Many of these physicians serve minority or rural populations, and those populations are now faced with significant challenges with regard to access to quality care. Not enough physicians translates to the stark reality that sick people in our communities are going without care, further exacerbating the disparity situation with which we are so concerned.  The NMA strongly advocates the enactment of federal legislation that offers common sense solutions that are equitable for all concerned.

Such solutions should include, among others:

· caps on non-economic damages in malpractice litigation
· reforming the process by which insurance companies set the premiums paid for malpractice insurance coverage
· a careful consideration of medical courts as a viable alternative to the tort system.

The NMA recognizes that injured parties do need a mechanism by which they can seek justice to redress medical negligence, but frivolous lawsuits and skyrocketing malpractice insurance premiums are driving America’s physicians out of business. A legislative response is desperately needed at the federal level. Unless we, as a nation, achieve a workable solution to resolve this dilemma, the hemorrhage of doctors leaving the practice of medicine will continue to drain the lifeblood out of our healthcare system. In the minority community, this is likely to translate into an exacerbation of healthcare disparities, given that minority providers are more likely to serve in minority communities.

Preserving the Healthcare Safety Net

As the “Conscience of American Medicine”, the NMA is very concerned about the preservation of the health care safety net. The services provided by the nation’s Medicaid program makes available a significant part of this safety net.  Medicaid services contribute signicantly to this safety net, the stewardship of which the NMA believes is a national responsibility.

Budget crises in many states are having devastating effects on Medicaid beneficiaries that are from minority communities. In states with substantial rural populations, this problem is even more acute. Sustaining the viability of Medicaid should therefore become an even more important priority, since Medicaid also pays for the lion’s share of the long-term care available in America’s healthcare system.

It is therefore with great interest that we observe the workings of the Medicaid Commission. The proposal from that body to trim several billion dollars from Medicaid’s budget for the next few years was met with dismay at the NMA. Unfortunately, the U.S. Congress has heeded the Commission’s advice. We are now resolved to work with the Commission during this critical phase that they are accepting ideas for long-term solutions to these questions.

Medicare Reimbursements

The Sustainable Growth Rate (SGR) is part of a complex economic formula for determining how much America’s doctors get paid for serving Medicare patients. The problem with the formula is that it is tethered, by statute, to gross domestic product (GDP), and our nation’s overall economic performance. So, when our economy experiences a slow down, the Medicare reimbursement rates are likely to trend downward. As a result, Congress has had to step in to prevent negative updates in the reimbursement rates.

With the escalating cost of providing medical care, negative updates in Medicare payment rates are simply untenable. That scenario places Medicare recipients at a greater health risk for negative outcomes because it fosters more physicians having to make the choice to “opt out” of the Medicare system. This is a vulnerable segment of our population [the elderly and disabled], and we must do all we can to improve the quality of their health care.

A growing number of leaders in our nation are now advocating the concept known as ‘pay-for-performance’. As the moniker implies, ‘performers’ will be paid, and others may not. The question, though, is whether this incentive-based mechanism will improve the quality of care delivered. Or, more importantly, will this approach improve health outcomes for our patients?

The platform for setting these standards is evidence-based. We remain concerned that the ‘evidence base’ will be developed among populations whose clinical characteristics are not representative of the populations served by the membership of the NMA. America’s most vulnerable will thus be written out of the script before the first curtain call. The NMA continues to negotiate the suggested processes for determining these standards.

Biological Hazards and National Security

Minority communities tend to work in those sectors of the economy that increase their exposure in the event of a bio-terrorist attack. The health literacy and health communication challenges that exist in minority communities are likely to impede effective responses to such an event. Consequently, special attention must be given to ensuring that communications networks prepare health materials and instructions that are written in clear and understandable language.

The threat of pandemic influenza highlights the urgency of this outreach. Bird flu, which has now proved fatal in multiple countries on at least 3 continents, requires a national commitment. We commend the White House on the steps that have been taken thus far to ensure optimal preparedness here in the United States.

Given the historical suspicion in minority communities of public health initiatives however, it is essential to have the appropriate buy-in and cooperation of minority populations in the event of a life-threatening biohazard or bio-terrorist event.

In order to establish that level of trust, preferably prior to any catastrophic event, it is imperative that ongoing education, sensitization, and positive reinforcement programs be established. 

NMA takes the position that the nation should educate physicians and other healthcare providers who serve minority communities as part of our nation’s preparedness efforts.

Healthy People 2010

The NMA strongly urges redirecting the nation’s attention to Healthy People 2010. This initiative is grounded in science, built through public consensus, and designed to measure progress. It was designed to serve as a roadmap for improving the health of all people in the United States, and builds on successful initiatives pursued over the last two decades prior to its adoption.

Healthy People 2010 had two major goals:  to increase quality and years of healthy life, and to eliminate health disparities. In order to achieve these laudable goals, the Surgeon General identified several focus areas from which key objectives and health determinants were derived. These focus areas included: access to quality health services, and the disease areas of cancer, chronic kidney disease, diabetes, and HIV/AIDS.

Consequently, the NMA endorses the strategies outlined in Healthy People 2010, and urges that its goals and the focus disease areas be revisited.

Universal Health Insurance Coverage

In its landmark report, Insuring America’s Health, released in 2004, the IOM concluded: 

Healthcare coverage should be universal.  Everyone living in the United States should be covered by health insurance.  Being uninsured can damage the health of individuals and families.  Uninsured children and adults use medical and dental services less often than insured people and are less likely to receive routine preventive care (Newacheck et al., 1998b: McCormick et al., 2001: IOM, 2002b).

Previous research on the subject has also revealed the following: They [the uninsured] are also less likely to have a regular source of care than are insured people (Zuvekas and Weinick, 199; Weinick et al., 2000).

Insuring America’s Health concludes by recommending that the following four components must characterize extension of health insurance coverage, including: 

1. Healthcare coverage should be continuous.
2. Healthcare coverage should be affordable to individuals and families.
3. The health insurance strategy should be affordable and sustainable for society.
4. Health insurance should enhance health and well being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable. 

The NMA embraces all of these principles. In our view, the moral imperative to insure the uninsured [45 million and counting] has never been more urgent.

If this were merely a moral argument however, then this could be relegated to political or sociological discourse. But the fact of the matter is that the uninsured are more likely to depend on emergency care as their first line of defense. The first problem with that is that the medical condition is probably much worse at that point than if intervention had occurred earlier. Secondly, it is more expensive, at that point, to treat it in the ER, and the follow-up treatment is likely to be even more complicated. 

We are mindful of cost considerations of early detection and preventive care, but we are not deterred from our conviction that universal healthcare coverage for all Americans is a goal worth pursuing.

As we stated in a previous section, the National Medical Association is prepared to collaborate with all citizens of goodwill in this great nation of ours in order to effect positive changes in America’s healthcare system for the benefit of all.