Over the RhineOver the RhineHealth Disparities Health Disparities

& Crossroad Health Center& Crossroad Health Center

Chuck Schubert MDChuck Schubert MDProfessor of Clinical PediatricsProfessor of Clinical PediatricsCincinnati Children’s HospitalCincinnati Children’s Hospital

University of Cincinnati University of Cincinnati

Over the RhineOver the Rhine

• German immigrantsGerman immigrants

• Beer production until prohibitionBeer production until prohibition

• Old housing stockOld housing stock

• Movement to the suburbsMovement to the suburbs

• Absentee landlordsAbsentee landlords

• Population shiftsPopulation shifts– Where did all the families go?Where did all the families go?

Poverty in the USA & Poverty in the USA & ChildrenChildren• Federal Poverty level: $22,000 Federal Poverty level: $22,000 (family of 4)(family of 4)

• 200% FPL: 200% FPL: Minimum to ensure clothing, housing & foodMinimum to ensure clothing, housing & food– 40% of children in families < 200%40% of children in families < 200%

(children only 25% of population)(children only 25% of population)

– 6% of children < 50%6% of children < 50%

• 400% of FPL = middle income 400% of FPL = middle income

FPL= Federal Poverty LevelFPL= Federal Poverty Level

• FPL based on “Thrifty Food Plan”FPL based on “Thrifty Food Plan”

• Assumes:Assumes:– 1/3 spent on Food1/3 spent on Food– 1/3 spent on Housing 1/3 spent on Housing – 1/3 spent on basic necessities1/3 spent on basic necessities

• Not updated Not updated (especially on cost of (especially on cost of housing)housing)

Poverty in Hamilton Cty, Poverty in Hamilton Cty, OhioOhio• 2.1 million people2.1 million people

• 18% of families (18% of families (22-27% of population22-27% of population) <FPL) <FPL– 32% under age 1832% under age 18– 15% over age 6515% over age 65

• National Average of cities >250,000 pop.National Average of cities >250,000 pop.– 13.3% 13.3%

Poverty & Cincinnati Poverty & Cincinnati

• 36% of children live below the poverty 36% of children live below the poverty lineline– 33rdrd in the nation in the nation – 82% live with a single mom82% live with a single mom

• One of the fastest-growing rates of One of the fastest-growing rates of suburban poverty in the nationsuburban poverty in the nation (Brookings Institution)(Brookings Institution)

Social Security Act of 1935Social Security Act of 1935• Economic assistance to the unemployed, the aged & Economic assistance to the unemployed, the aged &

low income widows & childrenlow income widows & children– Social Security:Social Security: Works: < 10% of elderly live in povertyWorks: < 10% of elderly live in poverty

• Old age survivor & disability insuranceOld age survivor & disability insurance

• Annual cost of living increaseAnnual cost of living increase

– Welfare:Welfare: not worked so well for kidsnot worked so well for kids

• AFDC now TANF: Temporary Assistance to Needy FamiliesAFDC now TANF: Temporary Assistance to Needy Families

• Limitations including welfare to workLimitations including welfare to work

– EITCEITC: earned income tax credit: earned income tax credit• Minimize or eliminate federal income tax for those living in below Minimize or eliminate federal income tax for those living in below

FPLFPL

• Lifts more children out of poverty than any other programLifts more children out of poverty than any other program

– Minimum wageMinimum wage: increased still less than 1960/80 real : increased still less than 1960/80 real dollarsdollars

Food Insecurity / Safety NetFood Insecurity / Safety Net

• Food stampsFood stamps– 49% of recipients are children49% of recipients are children

• School lunch & BreakfastSchool lunch & Breakfast• WICWIC (Women’s Infants & Children)(Women’s Infants & Children)

– Discretionary: Discretionary: only enough funds to serve 55% of eligible only enough funds to serve 55% of eligible

• Private SectorPrivate Sector: : – Food Banks, soup kitchens Food Banks, soup kitchens

What Controls Access to Health What Controls Access to Health CareCare

• Financial access (i.e.. insurance)Financial access (i.e.. insurance)

• Geographic distribution of physiciansGeographic distribution of physicians– Willingness to see the poorWillingness to see the poor

• Availability: Availability: transportation, office hours, etc.transportation, office hours, etc.

Why doctors don’t see the Why doctors don’t see the poorpoor

• Low reimbursementLow reimbursement

• Medically and socially complex Medically and socially complex patientspatients

• Negative perceptionsNegative perceptions– non-compliant, ungrateful, risk of law non-compliant, ungrateful, risk of law

suitsuit

• Difficult to referDifficult to refer

Why is Access Important?Why is Access Important?• Essential to prevent disease & promote Essential to prevent disease & promote

healthhealth

• If access is limited or denied for any If access is limited or denied for any reason there will be repercussionsreason there will be repercussions– as opposed to being a sudden tragedy, the as opposed to being a sudden tragedy, the

problems will be insidious problems will be insidious •Personal tragediesPersonal tragedies

•Unfulfilled potential (Pb poisoning) Unfulfilled potential (Pb poisoning)

•Health care becomes a privilege for the wealthy Health care becomes a privilege for the wealthy

•Cost of health care as a nation will be an issue Cost of health care as a nation will be an issue

Health disparities & Health disparities & How poverty affects child health?How poverty affects child health?

• Risk of decreased brain development Risk of decreased brain development – Poor living conditions Poor living conditions

• Inadequate housingInadequate housing

– Emotional stress of unstable environmentEmotional stress of unstable environment– Lack of nurturingLack of nurturing

• Why? Life priorities? Justice issues?Why? Life priorities? Justice issues?– Minimum wage, housing, nutrition, Minimum wage, housing, nutrition,

educationeducation

Health disparities & Health disparities & How poverty affects child health?How poverty affects child health?

• Decreased access to health careDecreased access to health care

• PB poisoning & anemiaPB poisoning & anemia– Developmental delaysDevelopmental delays

• Decreased exposure to readingDecreased exposure to reading– Speech & school readinessSpeech & school readiness

• Asthma Asthma – Story of 6 yr oldStory of 6 yr old

• ADHDADHD– Fewer options Fewer options

Health disparities & Health disparities & How poverty affects child health?How poverty affects child health?

• Safety issuesSafety issues– Prescription drugs ingestionsPrescription drugs ingestions– CO poisoning CO poisoning (space heaters)(space heaters) – Falls Falls (from windows)(from windows)

– Violence exposureViolence exposure

How does poverty affect child How does poverty affect child health?health?

• Low birth weight: doubledLow birth weight: doubled

• Lead poisoning: tripled Lead poisoning: tripled

• Delayed immunizations: tripled Delayed immunizations: tripled

• Death due to disease: 3 – 4 timesDeath due to disease: 3 – 4 times

• Death due to accidents: 2 – 3 Death due to accidents: 2 – 3 timestimes

• Severe iron deficiency: doubled Severe iron deficiency: doubled

What is Required for Child What is Required for Child HealthHealth• By health care providersBy health care providers

– AccessAccess– Comprehensive & preventive careComprehensive & preventive care– Supportive to parentsSupportive to parents

• Of parentsOf parents– Ability to pay for servicesAbility to pay for services– StabilityStability

• Of the communityOf the community– Freedom from conditions which increase risk Freedom from conditions which increase risk

• Pb, violence, vaccine preventable diseases, air & water Pb, violence, vaccine preventable diseases, air & water quality, quality,

• Dealing with poverty Dealing with poverty

Adult Health DisparitiesAdult Health Disparities

• ObesityObesity

• DiabetesDiabetes

• Hypertension Hypertension

• Mental Health treatment Mental Health treatment

My JourneyMy Journey

• Medical career melded with my faithMedical career melded with my faith

• 17 years in Cincinnati’s inner city17 years in Cincinnati’s inner city

• Founded Crossroad HealthFounded Crossroad Health– Treat all with dignity and respect Treat all with dignity and respect – More importantly lived in the same More importantly lived in the same

neighborhood as my patients neighborhood as my patients

• Time in ZambiaTime in Zambia– Value to my family Value to my family

ResidencyResidency

• September 1983: Relocated to OTRSeptember 1983: Relocated to OTR– Worshiped thereWorshiped there– Shopped thereShopped there– Kids went to school thereKids went to school there

• Built relationshipsBuilt relationships

• Plugged into projects Plugged into projects

• Identified with the community Identified with the community

A real job 1988A real job 1988

• Work in clinics in low income areasWork in clinics in low income areas

• Getting serious about health ministryGetting serious about health ministry Performed community assessmentPerformed community assessment Explored other models of health care Explored other models of health care Explored funding optionsExplored funding options Looked for community partnersLooked for community partners

All built on years of relationship building All built on years of relationship building

Health ClinicsHealth Clinics

• FQHC: Federally Qualified Health FQHC: Federally Qualified Health CentersCenters– 330 funds330 funds– Cost based reimbursementCost based reimbursement – But costs are never coveredBut costs are never covered

• Free ClinicsFree Clinics

• Faith-based Faith-based health centershealth centers (CCHF) (CCHF)– Chicago, Memphis, Washington D.C., Chicago, Memphis, Washington D.C.,

CincinnatiCincinnati

Planning BeginsPlanning Begins

• 1990: Christian Community Health 1990: Christian Community Health Services IncorporatedServices Incorporated

• 1990-1992 Secured Funds1990-1992 Secured Funds• Greater Cincinnati FoundationGreater Cincinnati Foundation• Robert Wood Johnson FoundationRobert Wood Johnson Foundation

Local Initiative PartnersLocal Initiative Partners

• Churches, IndividualsChurches, Individuals

Early Years 1992Early Years 1992

• Opened Part-time, evening hours, Opened Part-time, evening hours, 24-hour on-call coverage24-hour on-call coverage

• StaffingStaffing– Part-time staff physician, nurse, social Part-time staff physician, nurse, social

workerworker– Volunteer physicians Volunteer physicians – Full-time office administratorFull-time office administrator

• 200 visits in 6 months200 visits in 6 months

Crossroad Vision & MissionCrossroad Vision & Mission

• Show videoShow video

Crossroad StatsCrossroad Stats

• Provided almost 20,000 visitsProvided almost 20,000 visits

• 64% of patients are African American 64% of patients are African American

• 15% are Hispanic/Latino15% are Hispanic/Latino

• 15% are Caucasian15% are Caucasian

• 83% of patients have incomes 83% of patients have incomes << FPLFPL

• 39% of patients are uninsured 39% of patients are uninsured – 76% of uninsured patients are adults.76% of uninsured patients are adults.

Crossroad StatsCrossroad Stats

• National Diabetes Collaborative National Diabetes Collaborative

• Mental health counseling Mental health counseling

• Patients w/ hypertension Patients w/ hypertension – significantly better control of BP compared significantly better control of BP compared

to the national average: 60% are under to the national average: 60% are under control compared to 25% nationally. control compared to 25% nationally.

Crossroad StatsCrossroad Stats

• 96% of children screened for lead by age 2. 96% of children screened for lead by age 2. – 94% who were treated for lead achieved safer 94% who were treated for lead achieved safer

levels in 6 months. levels in 6 months.

• 96% of 3-year-old children were up to date 96% of 3-year-old children were up to date with their immunizations. with their immunizations.

• 83% of female patients had PAP smears, 83% of female patients had PAP smears, meeting state and national recognized meeting state and national recognized standardsstandards

Our Present Our Present LocationLocation

Natalie’s story Natalie’s story

• NatalieNatalie

• Eric showed up on our doorstepEric showed up on our doorstep

• The rest of the story… The rest of the story…

Conclusion:Conclusion:An abridged parable from the New An abridged parable from the New TestamentTestament

The parable is about a master intrusting his The parable is about a master intrusting his wealth to his servants. He went away for a wealth to his servants. He went away for a time and on his return those servants who time and on his return those servants who were faithful in using his wealth were were faithful in using his wealth were rewarded. rewarded.

Another similar parable end with a message to Another similar parable end with a message to a faithful servant (Luke 12:48)a faithful servant (Luke 12:48)

To the person who much is given, Much is To the person who much is given, Much is required…required…

But who is covered by But who is covered by what?what?

• 60% employer sponsored insurance60% employer sponsored insurance– Down from 72% in 1979Down from 72% in 1979

• 9% individually purchased insurance9% individually purchased insurance

• 3.5% Military insurance3.5% Military insurance

• 14% Medicare14% Medicare

• 12.5% Medicaid12.5% Medicaid

• 15.5 % uninsured 15.5 % uninsured

MedicaidMedicaid

• 67% SSI 67% SSI (Supplemental Security Income)(Supplemental Security Income)– Cash assistance for aged, blind and / or disabledCash assistance for aged, blind and / or disabled

• 19% for Non-disabled children19% for Non-disabled children

• 333 Billion333 Billion– 57% Federal dollars57% Federal dollars– 43% State dollars 43% State dollars