Health Disparities Span the State and Cost Billions Each Year. What Can Texas Physicians Do About Them?
Public Health Feature — June 2017
Tex Med. 2017;113(6):41-47.
By Sean Price
Some of Texas' worst health disparities get rolling in the cab of a truck.
"A lot of my [male patients] drive trucks, and truck drivers are our toughest group because of what they eat and because they're sitting in a cab all day," says John English, MD, who works at Bethesda Health Clinic, a faith-based clinic in Tyler that serves mostly low-income adults.
Truck drivers are tough patients because their work plays a role in their risk for various chronic ailments, according to the National Institutes of Health. They include higher-than-normal rates of obesity and hypertension as well as a prevalence of diabetes 50 percent higher than the general population.
Dr. English says a diabetes diagnosis alone can easily snowball into other health issues. Because of federal regulations, truck drivers have to get waivers to take insulin in order to keep their commercial driver's license. But those waivers can be hard to get and to keep.
"They're not wanting to take insulin because they could lose their job," Dr. English said. "So they're letting their sugar run high."
That's just one small snapshot of health imbalances in Texas. For another, go 100 miles or so west to South Dallas. There, some of Texas' greater health disparities are made worse by stray dogs. An estimated 9,000 canines prowl the area off leash, according to a report done for Dallas Animal Services. The big problem there isn't rabies, though that's a concern. The real issue is that the residents of those neighborhoods — mostly African-Americans and Latinos — are afraid to walk around.
"People in South Dallas buy golf clubs — not to play golf but to beat away dogs," said Eduardo Sanchez, MD, chief medical officer for prevention and chief of the Center for Health Metrics and Evaluation for the American Heart Association in Dallas. "Walking in your neighborhood, as your doctor is suggesting, it's going to be less likely if loose dogs are part of the landscape. It's just one of the things that makes being healthy challenging in South Dallas compared to North Dallas."
The picture can change again if you head to the colonias of South Texas or small towns in West Texas. Looking at health disparities anywhere can be complex and confusing. It can be especially so in a sprawling, diverse state like Texas.
To make things more confusing, health disparities can be defined in different ways. Some refer to rates of death or diseases that hit certain populations hardest. Others involve differences in health care services and access.
Start with the oft-cited fact that Texas has the largest population of uninsured people in the country — almost 5 million out of a population of 27 million in 2015. As with virtually all health statistics, the bad news falls heaviest on Hispanics and blacks. One study by Rice University and Episcopal Health Foundation said that as of March 2016, about 33 percent of nonelderly adult Hispanics were uninsured, compared with 14 percent of blacks and 10 percent of whites.
Dr. Sanchez says Texas physicians see the results in their offices because people without preventive care frequently suffer declining health. For instance, about 32 percent of Texas adults are obese. Yet the rates are especially high among African-Americans at 47 percent and Hispanics at 36 percent. Whites are below the average at 28 percent. The same is true of diabetes, with both African-Americans and Hispanics at 13 percent, and whites at 10 percent. Also, the prevalence of high blood pressure is greatest among African-Americans.
These imbalances cause economic as well as physical damage. A 2016 report by the Episcopal Health Foundation and Methodist Healthcare Ministries of South Texas found that disparities extract $1.7 billion a year from African-Americans and Hispanics in extra health care costs. Meanwhile, the same inequalities cost the state about $3 billion each year through lost productivity — largely from people not being able to work. They also translate into about 400,000 lost years of life.
Despite this heavy toll, there is a relatively low level of awareness about inequalities in health, says Jamboor K. Vishwanatha, PhD, vice president and director of the Texas Center for Health Disparities at the University of North Texas Health Science Center in Fort Worth. He says even people who are directly affected — including physicians and minorities — often express surprise that this is a problem for Texas.
"I'm amazed to find that many people are not even aware of it," Dr. Vishwanatha said.
What Causes Health Disparities?
Heredity has an undisputed impact on health. Perhaps the best-known example of a difference baked into the genetic code is Tay-Sachs disease, which tends to occur among people of Ashkenazi Jewish or French Canadian ancestry. Also, sickle cell anemia is more likely to occur among Africans and people of African ancestry.
But many health disparities are blamed too casually on genetics and race, says William Lawson, MD, associate dean for health disparities at The University of Texas at Austin Dell Medical School. For instance, African-Americans have an infant mortality rate 2.4 times higher than white Americans, as well as greater problems with low birth weights and premature births. These problems affect African-Americans of all education and income levels, so many have argued that the causes might be genetic.
But Dr. Lawson says the evidence does not support that idea. "If you go back and look at the ancestors of African-Americans, like those in Nigeria or people in western African countries, you don't find as much low birth weight or high infant mortality rates — even though these can be poor countries," Dr. Lawson said. "So the problem is not of genetics, but lack of access to services or failure to educate community members."
Most physicians learn about the "social determinants of health" — the conditions in which people are born, grow, live, work, and age. Dr. Vishwanatha says these can be broken down into four categories:
- Behavioral: any daily actions that affect health. For instance, low-income whites have very high smoking rates.
- Geographic: where people live, particularly areas where pollution and inadequate housing are common health hazards.
- Social and economic environment: discrimination faced in day-to-day life.
- Health care systems: What type of health care is available? This can include problems tied to insurance, lack of physicians or heath care providers, or inadequate care based on a factor like race or ethnicity.
These categories can be analyzed in many different ways; however, geography often plays an outsized role. A study released last year by The University of Texas Health Science Center at Tyler showed that the 35-county area that makes up Northeast Texas faces serious health problems. Northeast Texas ranks so high in chronic problems like heart disease and stroke that if it were a state, it would rank 45th nationwide in all causes of mortality. Texas currently ranks 31st.
There can also be disparities within the disparities. Unlike the rest of Texas, where whites are no longer the majority of the population, Northeast Texas is two-thirds white. Whites there have the highest mortality rates for some illnesses, like emphysema and Alzheimer's disease, but African-Americans in the region have higher mortality rates from chronic illnesses such as heart disease, stroke, breast cancer, and HIV-AIDS.
David Lakey, MD, is chief medical officer and associate vice chancellor of population health for the UT System. He says the problem in Northeast Texas is not necessarily access to health care. Compared with the rest of the state, people in Northeast Texas have roughly the same number of physicians available and similar health care coverage. But the area does have lower education rates, comparatively low incomes, and high tobacco use.
"If you looked at one region of the state that was the unhealthiest, it would be Northeast Texas," Dr. Lakey said. "The health outcomes are worse than in any other part of the state."
On that subject, Dr. Lakey has a "friendly disagreement" with Joseph McCormick, MD, regional dean at the UTHealth School of Public Health in Brownsville. Dr. McCormick says that the lower Rio Grande Valley, with a population that is 90-percent Hispanic, is easily the unhealthiest region in Texas. He says that shows up in many ways, including the way Medicaid funds are allocated.
Dr. McCormick cites the Texas Medicaid 1115 Transformation Waiver, which provides the state with about $29 billion in federal funds over five years. These funds go to hospital care for uninsured Texans and innovative care projects. Dr. McCormick points out that the money is allocated among 20 regions according to need. The three biggest population centers — Houston, Dallas-Fort Worth, and San Antonio — top the list, followed by the Rio Grande Valley.
"Think about it," Dr. McCormick says. "We don't have the population the size of Austin nor the size of El Paso. Yet we're allocated the fourth largest. The reason is that they use an algorithm that's based on access to health care and poverty. That ought to tell you that this is a very, very poor population."
But there's no need to crisscross the state to find health disparities. Just looking at the demographics within a typical city can bring them to light. Dr. Sanchez points out that Virginia Commonwealth University and the Robert Wood Johnson Foundation created life-expectancy maps for 21 U.S. cities, including El Paso. The El Paso map shows that life expectancy varies by 13 years, from a high of 84 years to a low of 71 years, depending upon where people live in the city.
"How can it be and why would it be that you can predict what someone's life expectancy could be based on where they live?" Dr. Sanchez says. "And is that OK? By the way, you can also predict the percentage of people who have uncontrolled blood pressure and a host of other health and socioeconomic issues based on ZIP codes as well."
Dr. Sanchez says all physicians should be familiar with this kind of information. Knowing the neighborhood a patient lives in can not only inform a diagnosis, but it can also help provide a practical treatment plan that takes into account neighborhood walkability, loose dogs, or the presence of food deserts.
"In some instances, there's a conflation of poverty and race or ethnicity because you're more likely to be poor if you're African-American, Latino, or American Indian," Dr. Sanchez says. "However, when you look at absolute numbers in Texas, more than 2 million Hispanics live in poverty, about 916,000 whites live in poverty, and 735,000 blacks live in poverty."
Many physicians, like Dr. English, are familiar with health inequalities because their practices focus on them. But Dr. Sanchez says most physicians are probably not aware of the extent of disparities in their area. County and state health offices can provide crucial information. So can national sources, like the 500 Cities Project by the Centers for Disease Control and Prevention.
Dr. McCormick says more physicians also need to learn about community resources that can help patients once they've left the exam room.
"[This is] not something that physicians are going to solve," Dr. McCormick said. "They have to be part of the solution to be sure. They have to play their role. But they can't just say, 'Mrs. Rodriguez, you have diabetes and here's a prescription. And, by the way, here's a flier to help you change your diet and get more physical activity.' That's a typical physician approach, and it's completely useless. It doesn't work. Physicians need to learn how to help people and help them find access to educational programs and community-based programs that can help them change their lifestyle."
Health disparities cost Texas billions of dollars each year. But the real economic impact is felt most in the places where disparities are greatest, Dr. McCormick says. Chronic conditions weaken patients' immune systems, exposing the whole community to a greater threat from infectious diseases. Lack of insurance and increased health problems are often paid for directly by hospitals and individual physicians. Dr. McCormick says the disparities in Brownsville, where he lives, have clearly held back the community economically.
"Let's say you're an employer and you're thinking of coming here," he said. "The cost of living is low down here, and the weather's good, and it's near the beach, it's semi-tropical, and so on and so forth. And then you say, 'Wait a minute: 28 percent diabetes? What does that mean if I want to start a business and hire people? What am I going to have to do regarding health insurance?' That is a big deal if you're going to start a company here."
Rose Zavaletta Gowen, MD, works as an obstetrician-gynecologist at the federally qualified health center Su Clinica in Brownsville and also serves as a city commissioner. She agrees that Brownsville's problem is "not just a health issue, it's an economic issue." Thirty-four percent of people there live below the poverty line, and census data show it's one of the poorest urban areas in the country. Eighty percent of the city's population — regardless of income level — is overweight, and diabetes alone costs the city $250 million in lost wages each year.
She says Brownsville is now working to turn around its fortunes by fixing its health inequalities. Local research has found that people who live within walking distance of a park or trail tend to exercise more. So the city recently created a master plan to create more sidewalks, Dr. Gowen says. The plan also calls for putting more walking or biking trails within a half-mile of everyone in the city. In recent years, Brownsville has created a farmers market, several community gardens, and free exercise classes. Meanwhile, bilingual community health workers called promotoras have fanned out to educate people about health care and connect them with community resources.
"We've seen a great response," Dr. Gowen says. "We see people change their behavior, to include fruits and vegetables in their diets. We've seen one bike shop become four bike shops. We've had a lot of success. We were even recognized by the Robert Wood Johnson Foundation as a Culture of Health winner a couple years ago."
Dr. Vishwanatha says lack of access to health care remains the biggest obstacle to tackling health disparities. But he says another key problem is a lack of minority physicians. He says many African-American and Hispanic patients mistrust white doctors because of past prejudice or because white doctors simply don't understand their culture and upbringing. Yet the statewide shortage of physicians is especially acute among African-Americans and Hispanics, and it seems to be getting worse. That's one reason Dr. Vishwanatha says combatting health disparities remains a "monumental task" in Texas. "I think we're only at the beginning of this," he said.
Dr. Lawson agrees that daunting problems still remain. But lawmakers and communities have already shown that disparities can be addressed if there is enough public will to do so.
"I think the important thing is that all these problems, given community interest, are solvable," he said. "We can make these changes."
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Editor's Note: In next month's issue of Texas Medicine, we'll explore how Texas medical schools are working to attract more African-American and Hispanic students.
TMA's Take on Health Disparities in Texas
Find out more — and help your patients find out more — about health disparities in Texas at TMA's Patient Safety Resource Center. Also find out more about how the lack of health insurance affects Texas physicians and their patients.
TMA Minority Scholarships
Since 1999, TMA has offered scholarships to incoming African-American, Latino, and Native American medical students. TMA selects the scholarship recipients from a competitive pool of applicants. Applicants must show outstanding interest in community service, health care experience, and academic standing. The scholarship program is made possible with a grant from the TMA Foundation thanks to the TMAF Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo; the TMAF Patrick Y. Leung, MD, Minority Scholarship Endowment; and generous gifts from H-E-B, and physicians and their families.
Find more information about or to make a tax-deductible donation to the TMA Minority Scholarship Program.
Poverty and the Myths of Health Care Reform
In 2016, the late Richard "Buz" Cooper, MD, published the groundbreaking book Poverty and the Myths of Health Care Reform. Commissioned by The Physicians Foundation, this book was the first to address the fundamental tie between health disparities and the soaring costs of health care. In the past, many analysts blamed rising costs on physicians, hospitals, and fee structures that they said created inefficiency and waste in the health care system. Dr. Cooper set out to show that the real culprits behind rising costs are income inequality and poverty.
Dr. Cooper's book does not focus specifically on Texas, but the evidence it lays out applies nationwide. The book also takes the Affordable Care Act to task. For instance, Dr. Cooper says that ACA's numerous regulatory hurdles encourage physicians to leave small practices and join larger medical groups. He says this means many doctors who might treat low-income people on their own find they can't when employed by larger organizations.
"ObamaCare," Dr. Cooper wrote, "was blind to the socioeconomic factors that underlie high health care utilization."
Dr. Cooper, a hematologist and oncologist, died at 79 from complications of cancer about six months before the book was published.
For more information, see The Physicians Foundation website.
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