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“Closing the Gap: Implementing Solutions to Health Care Disparities in New York”Daniel Laroche MDPresident, Empire State Medical Association,NYS National Medical Association affiliateAssistant Professor OphthalmologyNew York Medical CollegeNew York Eye and Ear InfirmaryPresident, Advanced Eyecare of New York

ama history with respect to black physicians
AMA History with respect to Black Physicians

1870: The integrated National Medical Society delegation was excluded from the AMA Annual Meeting in Washington, D.C.

1874: The AMA adopts a system of governance allowing state medical societies to determine which local societies will be recognized at AMA meetings, effectively allowing each state to decide the question of racial segregation.

1910: The AMA-requested Flexner Report, Medical Education in the United States and Canada, is published; the report recommends that all but two black medical schools be shut down.

1939: The AMA discontinues its policy of listing black physicians as "colored" in its American Medical Directory. The House of Delegates adopts policy discouraging racial discrimination in constituent society membership but allows it to continue.

1965-1968: The National Medical Assn. and the Medical Committee for Human Rights picket the AMA's meetings, protesting the Association's lack of action on state and county medical societies' racial exclusion policies.

american medical association apology july 2008
American Medical Association Apology, July 2008

The American Medical Association officially apologized in July for its history of excluding black physicians from membership, for listing black doctors as "colored" in its national physician directory for decades, and for failing to speak against federal funding of segregated hospitals and in favor of civil rights legislation.

"The AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine," said AMA Immediate Past President Ron Davis, MD,

Journal of the American Medical Association.

July 2007 Hawaii

July 2008 Atlanta

some progress has been made
Some Progress has been made
  • There are about 48,000 physicians in New York State
  • About 3,024 are self described as Black non Hispanic
  • Population of New York is 9 million with a Black population of 1.8 million
  • White physician/patient ratio is 1/150
  • Black physician/patient ratio is 1/595
study on black physicians in ny
Study on Black Physicians in NY

The number of Black physicians has not increasedsubstantially over the past decade and remains far less than

their corresponding proportion in the state’s population. Black physicians are more likely to practice in a primary care specialty and work in hospitals and clinics. They are alsomore likely work in areas of the state that are federally designated as primary care shortage areas.

Black physicians, improve the diversity and cultural

competency of the physician workforce, can increase access

to care and quality of care for underserved populations in New York

study on black physicians in ny6
Study on Black Physicians in NY
  • Black physicians were more likely to serve a higher percentage of Medicaid patients in their practices compared to all other physicians.
  • About one-third of Black physicians reported patient case loads of at least 50% Medicaid patients compared to slightly more than 11% of all other physicians.
  • There continues to be a tremendous shortage of Black physicians in New York State

Source: NYS Education Department Physician Re-licensure SurveyThe Center for Health Workforce Studies

cardiovascular disease
Cardiovascular Disease
  • Blacks in NY are 55% more likely to die of heart disease compared to whites at ages 45-54
cardiovascular disease10
Cardiovascular Disease
  • In the last 15 years heart disease hospitalizations increased in excess of 40% in eight mostly low-income neighborhoods:
    • Especially in Brooklyn
      • Increase of 94.4% in East New York
      • Increase of 78.5% in Bedford Stuyvesant-Crown Heights
      • Increase of 56.2% in Flatbush-East Flatbush
  • Black New Yorkers are 46% more likely to die from cancer than whites ages 45-54

Gregory Hines


Tap Dancer

Died of liver cancer

At age 57

Ben Carson




Prostate Cancer

breast cancer
Breast Cancer
  • The incidence of Breast cancer is over 40% higher among white women however more Black women die from Breast Cancer

Breast Cancer Stamp

  • In NY, 20% blacks suffer from diabetes
  • In the last 15 years hospitalizations have doubled in
    • South Bronx
    • East Harlem
    • Central Brooklyn

In 2005 the costs of an additional

3,100 hospitalizations in the

bottom two sixths neighborhoods

was $37 million. Much of it paid by

the public through Medicaid or

hospital charity pool.

  • 50% of Black women are obese
  • This increases risks for hypertension, heart disease, diabetes.
  • Black high school students in NY report the lowest rate of physical activity (over past 7 days), but the highest rate of television watching of 3 or more hours per day.
  • 50% of AIDS-related deaths in the city occur among blacks, who account for 25% of the city's population.
  • In addition, black women account for 34% of the city's new AIDS cases
  • Approximately one in five black men ages 40 to 49 living in the city is HIV-positive
  • Statewide, girls and women account for 48% of new HIV cases among people ages 13 to 19, and HIV prevalence among black women is more than 27 times higher than prevalence among white women
  • Black high school students report the highest rate of sexual intercourse and of forced sexual intercourse among female students

New York City Department of Health and Mental Hygiene

  • In NY, children in poorer neighborhoods are 3x as likely to be hospitalized for asthma than children living in wealthy neighborhoods.
  • Although the adult incidence of asthma are similar for Whites, Blacks and Hispanics, the death rates due to asthma is more than four times higher among Blacks than it is among whites

Rap star Coolio suffers from

Asthma and is a spokesperson

For the Asthma and Allergy



Kirby Puckett had to

Retire early from

Baseball and loss vision

In one eye from


  • Leading cause of blindness in the African-American and Afro-Caribbean community
  • Blindness rates from glaucoma are 4-6x higher in Blacks than whites

Ray Charles went

Blind from glaucoma

At age 6

Surgical Undertreatment of Glaucoma in Black Beneficiaries of

Medicare: Archives of Ophthalmology Vol 118, Feb 2000

infant mortality
Infant Mortality
  • In NY in 2006, the infant mortality of Black babies is 2-3 x that of whites.
lead poisoning
Lead Poisoning
  • In the year 2004, 6,200 children were identified with lead poisoning, 94% of the children are black
  • This continues to occur despite the fact that the NYC Dept. of Health banned lead based paint over 40 years ago
substance abuse
Substance Abuse
  • New Yorkers living in poorer neighborhoods are 4 times more likely to be hospitalized for substance abuse than those that live in wealthier neighborhoods.
mental illness
Mental Illness
  • Poorer New Yorkers are more than 2-6x more likely to experience serious emotional distress than those with higher incomes
  • Rate of Mental Illness in Fordham and Bronx Park 13%
  • Whereas, the rate of Mental Illness in wealthier Riverdale is 3%
  • For Brooklyn, roughly one in every 53 black 15-year-old males will die from homicide before reaching their 45th birthday.
  • By contrast, the average 15-year-old U.S. male faces a very low one-in-185 probability of being murdered before reaching the age of 45.
  • Most of this violence is Black on Black Violence.urdered before reaching age 45.
  • Chance of being a murder victim
    • White female 1:606
    • White male 1:106
    • Black female 1:124
    • Black male 1:29


James Davis

WK Kellogg Foundation, CDC

  • In NYS the jail budget is higher than the state education budget
  • Costs $40,000 yr to keep a prisoner in jail, this is enough money for a college Education
  • In Suffolk County NY Blacks make up 55% of the prison population and only 5% of the county
  • 63% of Black jail inmates were found to have a mental health problem
  • Being in jail is the single most deterrent to employment
what are the life expectancy and death rates
What are the Life Expectancy and Death Rates?
  • Average life expectancy is:

71.8 years for African Americans 77.4 years for Whites

  • Black Men- 68.3 years
  • White Men- 74.8 years
  • Black Women- 75 years
  • White Women- 80 years

Between 1990 and 2001, black men’s life expectancy increased by nine years and black women increased by 5 years. Whites increased too by ½ as much

disparities in educational funding
Disparities in Educational Funding
  • New York School districts serving poorer and minority neighborhoods receive $2152 less per student compared to school districts with fewer poor students
  • An average elementary school may have 400 students translating into a massive $860,800 difference
  • Lack of funding leads to lack of teachers, books, education….

The Funding Gap: Low- Income and Minority Students Receive Fewer Dollars by the Educational Trust 2002

access to medical care
Access to Medical Care
  • There are two million New Yorkers without health insurance
  • Poorer New Yorkers without health coverage are the most likely to not receive medical care.
  • However even those with private health insurance or Medicare continue to have racial/ethnic disparities in health.
  • “Race and income have substantial effects on mortality and use of services among Medicare beneficiaries. Medicare coverage alone is not sufficient to promote effective patterns of use by all beneficiaries “

Marian E. Gornick, M.S., Paul W. Eggers, Ph.D., Thomas W. Reilly, Ph.D., Renee M. Mentnech, M.S., Leslye K. Fitterman, Ph.D., Lawrence E. Kucken, M.P.A., and Bruce C. Vladeck, Ph.D. NEJM Vol 335:791-799, No. 11, 8/12/96

pt esmin green ignored to death in ny hospital emergency room
Pt Esmin Green Ignored to Death in NY Hospital Emergency Room

HHC President Alan D. Aviles said in a statement "It is clear that some of our employees failed to act based on our compassionate standards of care."

NYCLU Executive Director Donna Lieberman said at the time "The pattern of neglect and abuse at Kings County Hospital Center is an affront to human dignity,".

“There over 80,000 black patients like Esmin Green that die prematurely every year across the US due to healthcare disparities and lack of cultural competency.“

How many more deaths will be needed to enact statewide healthcare reform?

shortage of primary care physicians in minority neighborhoods
Shortage of Primary Care Physicians in Minority Neighborhoods

In 2004 there were 74 primary care physicians per 100,000 people in the bottom sixth neighborhoods of health outcomes

This is compared to 197 primary care physicians per 100,000 people in the top sixth neighborhoods of health outcomes.

mutual respect

We must all respect each other to prevent the atrocities and excess deaths from racism and discrimination

improve education by reforming the classroom
Improve Education byReforming the Classroom
  • Smaller class size enables more learning
  • Provide behavior consultants for those children in need
  • Comprehensive students assessments for those having difficulty
  • Improve teacher training
  • Tie teacher benefits to academic improvement in test scores
  • Preparation for employment and good health starts in kindergarten
improve education
Improve Education

Improve educational protocols in the zip codes with the highest health disparities: Rationale: Schools like the Harlem Village Academy Charter School should be a model for all NYC public school education. They have taken 5th graders performing in the bottom 25% of test scores and turn them around by the time they enter 7th grade to be in the top 5% of test scores city wide. They have a rigorous curriculum grounded in the highest expectations for all students. A caring and nurturing environment. They teach students to think deeply, independently, and critically. They have a longer school day from 7:30 am to 5:30pm with Saturday school and study hall for students whom need extra help and attention. They have a culture of accountability for academic achievement, a clear strict code of conduct that is consistent throughout the school and school uniforms that contribute to a culture of respect, scholarship, and community.

higher education almost eliminates the racial unemployment gap
  • Blacks armed with a four-year college diploma not only are far less likely to be unemployed, but the black-white unemployment gap is greatly reduced.
  • Employment leads to reduced poverty and greater access to healthcare.
  • Therefore, the historical two-to-one racial unemployment gap is reduced to 1.25-to-one for those with a college diploma.

“US Labor Department, June 2004”

improve self esteem of youth and educate about academic black heroes
Improve Self Esteem of Youth and educate about AcademicBlack Heroes

Improve the self-esteem of Black youth and educate all youth about the truthful significant historical contributions by Blacks to society today. The current educational system fails to teach the truth about history specifically the original contributions to civilization, science and technology by Africans via Ethiopia, Egypt, the Black Pharaohs contributions by the building of the pyramids. The first great physician Imhotep was an African physician. The teaching of the accomplishments of Blacks both ancient and modern in the New York City public school system would improve the self-esteem to Blacks to achieve and strive to become the future Black or American Heroes.

we need to train more black and black hispanic physicians
We need to Train More Black and Black Hispanic Physicians
  • More minority health care providers are needed especially since they are more likely to serve in minority and medically underserved communities
must support health pipeline recruitment development
Must Support Health Pipeline Recruitment/Development

*Support Reading Programs

Encourage all students to carry a book and read 1-2 hours a day.

Stop the notion in the Black community that reading is acting white, this is a concept that is still prevalent from slavery in many black communities.

Support Mentoring programs

Support educational summer programs and afterschool programs



improve health literacy and break language barriers
Improve Health Literacy and Break Language Barriers
  • More interpreters to overcome language barriers
  • Grassroots community based health workers to help patient navigate and access the health care system
  • Provide understandable patient education programs and materials to increase patients knowledge of how to access care
  • For patients whom cannot read, we must communicate effectively to our patients
educate individuals about personal responsibility
Educate individuals about Personal Responsibility
  • Increase physical activity
    • Walking, running, athletics, swimming
    • Expand physical education requirement in schools at least 3x/week
  • Health diet
    • Increase water intake, vegetables, fruit, lean chicken and fish
    • Avoid high caloric fats, red meats, starches, soda, juices
  • Healthier behavior
    • Avoid premarital/unprotected sex, smoking, drinking, substance abuse

Reduce Stress

must stop prevent tobacco use
Must Stop & Prevent Tobacco Use
  • Most preventable cause of death in our society accounting for 30% of all cancer deaths
  • Causes nearly 87% of all lung cancers
  • People who quit before the age of 50 cut their risk of dying in the next 15 years in half
  • A Major Cause of Cardiovascular disease
  • 80% of smokers begin to smoke before the age of 18
if crime is down 30 why is incarceration up
If crime is down 30% why is incarceration up?

There is racial bias at every stage of the criminal justice system including policing, arrests, sentencing and parole.

In Suffolk County Blacks make up 7% of the population but 40% of the jail population.

In Rensselaer County Blacks make up 5% of the population but 35% of the jail population.

We MUST STOP DISCRIMINATION, The statistics are not a result of more criminal behavior in the Black community

We must Stop the State Commission of Corrections from mandating the construction of correctional facilities in NYS

We must institute contract controls to monitor how contracts are distributed and their impacts on taxpayers

prevent the incarceration of black men
Prevent the Incarceration of Black Men
  • Education
  • Community Centers
  • After school programs
  • Provide comprehensive behavior intervention for those whom may be in need
  • Re-educate and provide job training and transition programs to those incarcerated and to be released
  • Provide mental health to those in need
  • Stop racial discrimination I policing and stop arrest quotas
bring divert court model from dallas texas to ny to reduce incarceration
Bring Divert Court model from Dallas Texas to NY to reduce incarceration

Established 10 years ago Divert Court has been shown to have a tremendous cost/benefit savings.

On average, for every $1 spent on upgrading drug treatment and diverting offenders from traditional incarceration, to drug treatment through DIVERT Court, $9.43 of costs can be saved by society over a 40 month post-treatment period.

Emphasis is place on rehab and treatment and avoiding incarceration


alternative to jail construction
Alternative to Jail Construction

Creating Pre-Arrest Programs, Citation programs to avoid initial booking

Programs for the mentally ill

Improve release procedures and the pretrial and sentenced populations

Specialty courts, drug court, mental health court, domestic violence court

Alternative punishment to incarceration including expanding probation

All suggestions will save NYS taxpayer millions of dollars

youth conflict resolution and legal education
Youth Conflict resolutionand Legal Education

Create violence reduction, conflict resolution, and preventive law education protocols for junior high school students and public: Rationale: This will help reduce prevent incarceration. The state does not allow religion to be taught in schools. Thus there is a void in the teaching of morals and principles of right and wrong. Children coming from poorer families often have parents away from the home working 2 and 3 jobs to make ends meet and maybe deprived of this nurturing. The educational system must participate in educating students about the consequences of criminal activity.

We must also have funding for research identifying the most common zip codes with incarcerated minority youth, and identifying the reasons for incarceration and create programs to prevent this adverse outcome in those specific zip codes.

nyc take care new york
NYC “Take Care New York”
  • Have a regular doctor
  • Be tobacco free
  • Keep your heart healthy (control weight, Cholesterol, BP)
  • Know your HIV status
  • Get help for depression
  • Live free of dependence on alcohol and drugs
  • Get checked for cancer
  • Get the immunizations you need
  • Make your home safe and healthy from lead
  • Have a healthy baby, obtain prenatal care

NYC Department of Health and Mental Hygiene

cultural competency
Cultural Competency

Legislation must be enacted to ensure Mandatory Cultural Competency for all Physicians and Healthcare Workers in New York State. All licensed healthcare workers in New York must be made aware of the terminal effects of prejudice in healthcare on ethnic minority groups in New York State. David Satcher M.D. the former U.S. Surgeon General estimates there are over 83,570 annual premature deaths due to prejudice in healthcare. Dr. Nelson Adams the 111th President of the National Medical Association states: "Cultural competency education is urgently needed, racial inequities in healthcare will never be scientifically justified, politically excusable, and never morally acceptable".

health insurance reform
Health Insurance Reform

Eliminate Health maintenance organizations: Rationale: Health maintenance organizations are a middle man in medicine. They deliver no health care and have the best interests of the their investors, shareholders, and executive compensation. Recently the CEO of United Healthcare Dr. McGuire earned 1.6 billion dollars in stock options. Instead of this money being invested for infrastructure in healthcare it is being used for personal use. Legislation must be passed to make healthcare a basic human right and not a privilege.

There are over 2 million New Yorkers without health insurance. The concepts of referral use and capitation by HMO’s only discourage the physician patient encounter delaying health care decreasing access to health care.

This has led to many hospitals closing in New York and physicians closing their offices. In New York hospitals lose approximately $750 million dollars annually and the HMO’s profit over 750 million dollars. Getting rid of HMO’s and centralizing care to a few would reduce the amount of money spent on administration and allow patients, and hospitals to thrive. More patients would also be able to obtain insurance with the expansion of the Medicaid, Child health plus program, Health NY program and Medicare program to insure all New Yorkers.

diversify the leadership at the nys department of health
Diversify the leadership at the NYS Department of Health

Black employees at the Department of Health are sorely underrepresented, <2 %

Black employees at the department of health are tracked into locations where the pathways to promotion have been eliminated.

NYS DOH must include health disparities in all efforts addressing healthcare for New Yorkers.

Current NYS DOH organizational infrastructure encourages and perpetuates unequal promotion, unequal distribution of resources further exacerbating healthcare disparities.

nys dept of health call to action
NYS Dept of Health Call to Action

Must expose and eliminate deeply embedded pathways, procedures and practices that foster unequal geography of institutional opportunity.

Increase the ability of Blacks and Latinos to build and maintain knowledge and leadership capital, maximize growth potential, and be promoted within the department of health.

Bring the Office of Minority Health from the fringe to the core of the public health system

Relocate the Office of Minority Health to the Office of the Commissioner of Health

Increase funding to the NYS Office of Minority Health, recently its budget has been decreasing from >1 million dollars to $693,000.

Articulate a clear vision and a comprehensive plan with performance measures towards eliminating health care disparities.

nys governor issuing an executive order
NYS Governor: Issuing an Executive Order

Issue an Executive Order to require that each state agency shall make eliminating inequities part of its mission by identifying and addressing as appropriate, disproportionately high and adverse human health and environmental effects of its programs, policies and activities on minority populations and low income populations in New York State.

Encourage the Attorney General’s Office to challenge systematic inequities in the health care system including public health.

consider banning alcohol and tobacco advertising in ny
Consider Banning Alcohol and Tobacco Advertising in NY

These companies advertise heavily in Black and Latino communities in NYC leading to increased disease and disparities in Southeast Queens, Central Brooklyn, South Bronx and Harlem. Banning these ads will help stop the glamorization of these destructive products.

The smoking ban in public places has worked well to reduce the number of new smokers.

positive public health educational ads on radio and tv
Positive Public Health Educational Ads on Radio and TV

Create and enhance preventive public service announcements.

Educational advertisements regarding diet, exercise, substance abuse, smoking, sexually transmitted diseases will help prevent premature death from cardiovascular disease, cancer, homicide, HIV .

Educational announcements of reducing asthma by reducing air pollution and household mold.

Advertisements via radio, television, billboard posters and press conferences are very effective toward educating the public about the latest health alerts, issues and action initiatives.

Stop Medicaid Cuts to Private Physicians to allow greater access for patients to have a medical home

Repeal the New York Medicaid cuts for healthcare for those patients with dual Eligibility with Medicare: These cut backs have reduced patient’s access to private physicians in poorer and underserved neighborhoods.

The cutbacks also discourages physicians from setting up practices in poor communities since they will be receiving less reimbursement than physicians whom practice in wealthier communities.

Physicians that open up their primary practices, (>50% time) in poorer underserved neighborhoods in designated zip codes in central Brooklyn, Southeast Queens, South Bronx, and Harlem, should also receive special state and city income tax and property tax breaks to offset student loans and lower income received from serving these communities and receive increased reimbursement.

tort reform
Tort Reform

Tort reform with caps on malpractice awards. This will ensure more funds available for healthcare instead of trial lawyers that on many occasions file frivolous lawsuits costing healthcare providers millions of dollars depleting monies for healthcare.

Ob-Gyn Malpractice insurance in NY ranges from $150,000 to $250,000.

7 counties in NYS do not

have an Ob-Gyn as a result of this.

tort statistics
Tort Statistics

The average medical liability award has gone up 35% to $8,134,102.

The civil justice system frequently produces awards where there has been no negligence

In many cases where there has been negligence the system often produces no payments to the plaintiff

Physicians are now increasingly being forced to view their patients as potential plaintiffs rather then person in need of care

Over the past 10 years MLMIC has spent of $500 million to defense physicians and hospitals on whose behalf no payment was ever paid to the plaintiff that filed a claim.

tort statistics60
Tort Statistics

In NY 71% of Neurosurgeons have been sued

In NY 67% of Ob-Gyns have been sued

No other level of human activity is the source of such lawsuits

Many hospitals have close their OB-Gyn divisions

tort legislative recommendations
Tort LegislativeRecommendations

Special health courts

No-fault system for claims involving neurologically impaired infants and emergency department care.

Most neurological conditions involve impairment prior to birth.

Tightening of rules of whom can be an expert witness in a medical liability action.

Disclosure of the identity of an expert witness in a medical liability action prior to trial.

Expert witnesses must be practicing the same specialty as the physician whom against whom the lawsuit if filed.

$250,000 cap on non-economic damage awards.

tort reform legislative recommendations
Tort Reform Legislative Recommendations

State-funded subsidy and/or tax credit to defray the cost of medical liability insurance.

Create a “clear and convincing” standard of proof in medical liability actions, a higher standard than the current “preponderance of the evidence standard”

Impose a $10,000 fine on an attorney who brings frivolous action and enforce the penalty

Immunity for Apology- 27 states have and “I’m sorry Law” to protect health care providers who express sympathy to a patient for an unanticipated outcome from having such a statement used against the health care provider in any subsequent litigation that may arise.

50% discount on malpractice premium for those physicians that practice in zip codes affected by the highest healthcare disparities

contact medical schools to invest in diversity as well as research
Contact Medical Schools to invest in diversity as well as research

Contact all local New York Medical Schools and Hospitals to immediately enforce nondiscriminatory laws by recruiting underrepresented Black and Hispanic physicians, medical students and health personnel: Currently New York City is 60% Black and Hispanic. The number of Black and Hispanics in New York Medical Schools are 5%. The leadership in both medical schools and hospitals has failed to diversify and support the medical staff to address current healthcare disparities.

Reduce the cost of medical education.

blue white collar job technology training
Blue/White collarJob & Technology Training

In some areas of NY as much as 51% of Black men in are unemployed.

Immediately develop job-training programs: Unemployment leads to poverty, substance abuse, and crime. Not only are the men affected but also the women and children of the family.

reduce the cost of prescription medications
Reduce the cost of Prescription Medications

Globally Drug companies make 50% of their profits off of the American consumer alone. Pharmaceutical cost reduction protocols such as those used in Canada and other countries will reduce the cost the medications particularly for patients whom are poor and may not be able to afford them to reduce health disparities.

Legislation must be considered to reduce the mark up of medications.

Parallel importation of drugs will stimulate free enterprise and reduce the costs of medications as is seen in Europe.

we are against retail health clinics
We are against Retail Health Clinics

Patients need to see physicians in a “medical home” at their doctor’s office, not a drug store clinic that bombards them with unhealthy candy, chips, soda and food as you enter the drug store.

Doctor don’t spend 8-15 years of their life training to work out of a retail drug store.

All of the above recommendations should be targeting the zip codes in New York that are clearly known to have these disparities in health, education, and unemployment. Specifically Central Brooklyn, Uptown Manhattan, South Bronx, Southeast Queens.

Areas most in need:

Harlem, So. Bronx, Central Brooklyn

failure to address healthcare disparities will lead to
Failure to Address Healthcare Disparities will lead to:
  • Increased taxpayer costs for healthcare
  • Increased waste of resources for healthcare
  • Increased social service costs
  • Decreased productivity
  • Decreased national and global competitiveness of New York City and New York State
  • Will you be part of the problem or part of the solution to address healthcare disparities in New York?