Earlier this year, Dr. J. Nadine Gracia seemed to be everywhere. She's the first woman in 17 years to lead the Office of Minority Health, and she was on the media circuit promoting Minority Health Month in April and the OMH's recent partnership with the American Diabetes Association. The calm and collected face of the OMH, Gracia articulates its goals and represents the OMH well. But beneath that stoic government exterior, Gracia and her agency are preparing for battle, and have been for some time, as plans set in motion are finally starting to coalesce. They are ready to end for good the health disparities that have plagued the nation.
Gracia, M.D., M.S.C.E., is the acting Deputy Assistant Secretary for Minority Health and the Acting Director of the Office of Minority Health at the U.S. Department of Health and Human Services (HHS). She draws on numerous skillsets and professional backgrounds: pediatrician, clinical instructor, and government officer. From 2008– 2009, she worked at the HHS as a White House Fellow, including a two-month period advising First Lady Michelle Obama in her childhood obesity initiative. Gracia then served as the Chief Medical Officer for the HHS Office of the Assistant Secretary for Health from 2009–2011. The undercurrent in all these positions? A commitment to eradicating health disparities and improving child health, particularly among the impoverished.
Other initiatives include the "Million Hearts Campaign," an HHS-wide priority led by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), aimed at preventing a million heart attacks and strokes in the next five years; supporting the adoption of electronic health records projects amongst health practitioners in minority neighborhoods funding community-based organizations to do outreach and education (led by the Office of the National Coordinator for Health Information Technology); and the HIRE program, a resource for HIV-positive exoffenders looking to return to the working world.
Then there are the HHS Action Plan to Reduce Racial and Ethnic Health Disparities and the National Stakeholder Strategy for Achieving Health Equity. With these initiatives, it seems as though the U.S. government, and the Department of Health and Human Services in particular, are redoubling their efforts concerning eliminating health disparities—pinpointing causative factors and implementing research-based solutions. In addition to quelling rampant health disparities, the initiatives hope to deliver more culturally competent care while recruiting and retaining a more diverse workforce.
But where do the boundaries of health care lie? For Gracia, it's certainly not the perimeter of a hospital. Health care disparities have their roots in socioeconomic and environmental factors much more pervasive than that. The disparities aren't going to go away through systemic health care improvements alone. As the work coming out the Office of Minority Health demonstrates, it's clear that nationwide, bigpicture interventions are needed to change health outcomes in the United States. "Many of the underlying risk factors that contribute to health disparities are the result where we live, learn, work, and play," says the OMH's website. These social determinants of health extend far beyond the realm of health care as practitioners know it. "Eliminating health disparities will necessitate behavioral, environmental, and social-level approaches to address issues such as insufficient education, inadequate housing, exposure to violence, and limited opportunities to earn a livable wage."
A first-generation Haitian American born and raised in the United States, Gracia says her cultural heritage strongly influenced her life and work.
The youngest of four, Gracia says she learned about service and helping the less fortunate from her parents. Even with her family coming from one of the world's most impoverished nations, she says she saw the same disparities in the United States as in Haiti. In med school, in the greater urban population, in all of public health: the inequalities she saw led Gracia to her current work. In fact, she says the reason and mission of the Office of Minority Health inspired her to go into medicine initially. Gracia always had a passion for advocating for vulnerable populations, she says. The Student National Medical Association, where she served as president, opened her eyes to helping underserved populations at the government level, further motivating her toward entering the field of public health.
And now she's at the pinnacle, helming the organization overseeing sweeping public health care overhaul. But as government offices hoping to implement widespread changes typically do, the OMH faces certain challenges, including minorities' access to health insurance, higher insurance rates than the general population, and barriers to visiting providers. And when minorities do go to the doctor, they receive a lower quality of care and are less likely to receive preventive care, Gracia says.
Yet, it's still an exciting time to work in public health, with the Affordable Care Act steeped with resources and tools to overcome overarching health disparities, helping to define priorities in the health care system. Health care law is just that—law—Gracia says, and upholding the law is a duty and responsibility not to be shirked.
Already Gracia has seen great strides in health care, she says. Political turmoil aside, the task now is implementing the law and making sure communities really understand all its provisions and how to benefit from them.
The OMH is able to address one of the key barriers to eliminating disparities: providing increasingly better access to care, Gracia says. The Health Resources and Services Administration (HRSA) is investing in community health centers, expanding services at existing centers, and creating safety nets in the neediest communities.
Gracia says her office and organizations like the National Health Care Services Corps also understand the import role nurses play in implementing and developing these initiatives in community clinics, hospitals, and beyond. "It's really a remarkable time for the nursing profession," she says. "The work that they're doing is so vital." Nurses are "on the ground," as they say, and can often provide essential culturally competent care, act as patient liaisons, and offer valuable feedback to administrators.
Gracia further emphasized the importance of nursing, as the country is enveloped in a dialogue (albeit contentious) concerning health care. It's an opportunity to finally and comprehensively combat the disparities that have affected the nation for far too long, she says. Health equity means everyone has the opportunity to lead a healthy life, Gracia says. Improving the health of minority populations helps improve the health for anyone, and she encourages minority nurses and nursing students to continue their work toward achieving that end.
Gracia and the OMH/HHS initiatives under her leadership are developing or implementing strategies communities can employ, such as nursing students/organizations taking the pledge to address local needs. She emphasizes the role nurses play during this important moment in history, saying she would reinforce the nursing profession as the OMH makes prevention its focus. Nurses can lead their departments in educating and fighting disparities, and they can coordinate local and national partnerships. "We have support of our national leaders who see this as a priority," she says, because when it comes to eliminating disparities and promoting health equity, now is the time.
Together, the Affordable Care Act, the HHS Action Plan to Reduce Racial and Ethnic Disparities, and the National Stakeholders Strategies leave Gracia especially hopeful. "These three initiatives are really giving us the foundation we need to reduce these disparities," she says. "We have a national partnership for action." They've outlined actions committees can take in increasing awareness, improving cultural competency, and improving data, as a better understanding of disparities is necessary to eliminating them. They now have a way when there had always been a will.
The Patient Protection and Affordable Care Act has been a part of the health care (and political) landscape for over two years now. Though many provisions are yet to be rolled out, it has already led to a boost in funding that Gracia hopes will herald the beginning of the end of health care disparities.
Limited access to preventive care and lack of insurance coverage: these are some of the main issues contributing to disease disparities amongst minorities. But the Affordable Care Act has thus far provided 86 million people with free preventive services, like diabetes screenings (one of the chief health care concerns among racial and ethnic minorities). Increased funding to community health centers in underserved communities should also improve access and quality of care. Regarding health insurance, industry overhauls have led to more and better-insured individuals, particularly amongst children, young adults, and the elderly. For example, by allowing children to remain on their parents' insurance plans until the age of 26, the Act extended care to 2.5 million people, half of which are minorities.
Preventive care is recognized as one of the most effective ways of reducing health disparities, particularly regarding pediatric care. It's a bit of a chicken-and-the-egg scenario when it comes to child health, as poor maternal health impacts the child's. And it's a fiscal issue as well, as healthy lifestyles (and lifetimes) reduce the pressure of treating costly illnesses like diabetes, hypertension, and heart disease later in life. "Health status should be of concern to policymakers in all sectors, not just health-related sectors—to develop policies and programs that tackle the fundamental causes of health inequity," says the OMH.
The National Partnership for Action to End Health Disparities (NPA) is reaching out to "frontline" stakeholders—like nurses—by name. It's a "bottom up" approach, charging practitioners with the responsibility of helping devise responsive solutions after they identify health disparities when and where they appear.
The NPA works in tandem with the other initiatives, helping them move closer to health equality in a sustainable, comprehensive way.
They want the practitioners to identify what needs to be done to close the health disparity gaps, and who works more closely with affected patients than nurses?
The watchdog-esque NPA is also responsible for the National Stakeholder Strategy for Achieving Health Equity, the goals of which are, chiefly, to improve the quality of life and health for the underserved, such as racial and ethnic minorities; to increase awareness of the disparities plaguing the health care system; to strengthen the leadership of organizations fighting disparities; to impart cultural competency; and to improve research and data collection.
Four goals define the National Stakeholder Strategy:
"A roadmap for eliminating health disparities through cooperative and strategic actions," the National Stakeholder Strategy is the product of careful deliberation and community discussion, including "Community Voices" and "Regional Conversations" meetings, where the HHS gleaned insights from business, academic, and community leaders in 10 HHS health regions. These conversations helped the agency "define, refine, and collaborate," and a Federal Interagency Health Equity Team led the effort.
Solutions devised by the NPA will be implemented in two ways: according to National Stakeholder Strategy's Regional Blueprints for Action (a resource that will help at the local, state, and regional levels) and through targeted initiatives coordinated with public and private sector partners.
The NPA and its dialogues also spurred the development of the HHS Action Plan to Reduce Racial and Ethnic Health Disparities, released in conjunction with the National Stakeholder Strategy, the third facet of Gracia's and the OMH plan for diminishing health disparities.
Along with the National Stakeholder Strategy came the Action Plan to Reduce Racial and Ethnic Health Disparities, which builds upon the Patient Protection and Affordable Care Act. The main provisions of the Act—to foster wellness initiatives and bolster preventive care, to make health care costs more manageable, and to build infrastructure—make the Action Plan possible. The Action Plan, in turn, outlines the HHS's next steps.
Minorities still experience the socioeconomic disadvantages that lead to poorer health outcomes. According to the Department of Health and Human Services, "They are less likely to get the preventive care they need to stay healthy, more likely to suffer from serious illnesses, such as diabetes or heart disease, and when they do get sick, are less likely to have access to quality health care."
Common issues highlighting disparities include heart disease, HIV/AIDS, and respiratory diseases. Minorities are also more likely to experience disproportionate levels of violence, infant mortality, and poor oral health.
Eliminating these disparities is the dream; reducing them is the current goal. The Action Plan outlines five steps to do so.
The tools, the commitment, the support of the federal government, the will of an eager health care workforce, and a leader with a clear vision and desire for change: it's the perfect storm of a solution to health disparities. As time passes, the nation will watch—and nurses will see from the inside—how these three initiatives and Gracia work together to make it happen.