Health Equity After 2016 November 19, 2016

1. Health Equity After 2016November 19, 2016 Mary T. Bassett, MD, MPH Commissioner New York City Department of Health and Mental Hygiene CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of DOHMH is strictly prohibited

2. Past as Prologue Volunteering for the Black Panthers Resident at Harlem Hospital

3. And in 1980… • Ronald Reagan elected President • Social service cutbacks follow • Harlem Hospital a front row seat • No CT scanner • Shortage of respirators • OR suites closed due to lack of air conditioning • Ran out of penicillin

4. “Ideology and politics penetrate scientific theory and research. […]To unravel and eliminate black-white differences in disease, we must begin by politically exposing, not merely describing, the social roots of suffering and disease. […] In order to target the social forces which produce disease, we must begin to develop an antiracistmodel of disease causation”

5. 2016 Election Exit Polls New York Times, Edison Research for the National Election Pool, 2016.

6. Excess mortality reduced 2004 black voting age population by 1.7 million Kerry lost 900,000 votes and Bush lost 100,000 to black excess death. Outcomes of 7 senate and 11 gubernatorial races could have reversed.

7. Preliminary Thoughts on Impact on NYC Government • Federal Grants for Preparedness & Response Uncertain • Non-Communicable Diseases Efforts • rules at HUD, FDA, USDA • ACA: Increase in uninsured rate, Medicaid waivers (DSRIP) and Prevention & Public Health Fund in jeopardy • Reauthorization of CHIP, Farm Bill, WIC, Hunger Free Kids Act

8. Augmented Threat to NYC’s Public Hospital System • 26%of total patient volume at public hospitals were uninsured, vs. 6%academic medical centers (AMCs);9% private hospitals • Public hospitals provided 52% of uninsured care in NYC, vs. 21% AMCs; 28% private hospitals • Public hospitals provided 58% of uninsured care in NYC but received only 12% of indigent care pool (ICP) funds. • $139 million in ICP is allocated to public hospitals and $994 million to private hospitals TikkanenRS, Woolhandler S, Himmelstein D. The New York Indigent Care Pool: Is there a relationship between hospital allocations and uninsured patient volumes among New York City hospitals? APHA 2016.

9. Medicare for All • PNHP has been a steadfast voice for single payer health care • Faster, cheaper, better care But now… • Single Payer system now more remote • Flawed ACA under threat • Medicaid under threat • Much unclear, but much to worry about

10. Why We Need to Talk About Racism • Health care delivering unequal outcomes • Race has major impact on • Disease occurrence • How long we live • US health compares terribly to peer nations AND • We spend more by far on health care services

13. Institute of Medicine, 2013

14. History in Perspective

15. Growth of Enslaved Labor • As indentured servitude shrank due to increased economic gains, large planters dominated the tobacco industry. • shift from European indentured servants to African slaves • Chattel slavery was a lucrative investment for wealthy southerners • Slave financial benefits extended to the north

16. The Slave Codes • Property rights for slave owners • Free trade of slaves • Prohibition of arms ownership among blacks • Prohibition of blacks striking whites for any reason • Prohibition of blacks employing whites

17. Institutionalizing Racism • Dehumanization of people of African Descent • Chattel property • 3/5 of a Human • Established Slave Codes ENSLAVEMENT OF AFRICANS 1619 - 1865 • Development of Black Codes • Sharecropping • Mass Lynchings RECONSTRUCTION 1865 - 1877

18. Codified Racial Segregation in Law • Developed Institutionalized practices for de jure segregation • Depictions of Black Caricatures • Mass Lynching JIM CROW PERIOD 1890 - 1965 • Civil Rights Acts • Advent of Globalization. • Systematic Dismantling of Black Power Movement • Mass Police Killing CIVIL RIGHTS 1965 - 1980 • Mass Incarceration • War on Drugs • War on Gangs • Disproportionate Police Surveillance • Stop and Frisk • Operation Clean Halls • Mass Police Killings PRESENT DAY 1980 – Present

19. Premature Mortality by Income, Race People of Color in Lowest Income Counties Whites in Highest Income Counties Source: Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., & Kennedy, M. (2008). The fall and rise of US inequities in premature mortality: 1960–2002.  PLoSmedicine, 5(2), e46.

20. Infant Death Rates by Income, Race Source: Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., & Kennedy, M. (2008). The fall and rise of US inequities in premature mortality: 1960–2002.  PLoSmedicine, 5(2), e46.

21. Infant Death Rate (per 1,000 LB) in New York City Source: NYC DOHMH Bureau of Vital Statistics; compiled by BMIRH

22. Approximately 176,000 deaths in the United States in 2000 were attributed to racial segregation and 199,000 to income inequality.

23. Zip Codes and Genetic Codes

24. Residential Segregation by Race in New York City Dissimilarity Index Data source: NYC DOHMH population estimates, matched from US Census Bureau intercensal population estimates, 2010-2013, updated June 2014 U.S. Census Bureau; American Community Survey, 2013 3-year Estimates, Table S1701; generated using American Fact Finder (http://factfinder2.census.gov/)

25. NYC’s Sickest Neighborhoods

26. Elementary School Absenteeism Jail Incarceration Rate (per 100,000) Health as a Social Outcome Poverty Unemployment

27. Inequities are not Immutable Jim Crow and US Infant Death Rates Source: Krieger et al Am J Public Health, 2013

28. Bringing Data to Communities

29. Health Equity in Emergency Jan - Feb Mar – Apr May - Jun Jul - Aug

30. Learn to Swim

31. Neighborhood Health Action Centers • Opening 3 Action Centers in 2016: Brownsville, Tremont, East Harlem • Services will include: • Primary careand dental services • Legal services • Youth programming • Mental Health services for children and families

33. Critical research • Internal reform • Public advocacy

34. Speaking Out

35. Questions