This article first appeared in the St. Louis Beacon, Dec. 26, 2010 - Whether the event is a panel discussion on health reform or the opening of a community clinic, one familiar face in the audience or on the stage is likely to be Dr. James R. Kimmey.
A witty speaker with extensive knowledge on a range of health-care issues, Kimmey is the founding president and CEO of the Missouri Foundation for Health. He previously was dean of the School of Public Health at St. Louis University and is also emeritus professor of health administration and policy at the school. He regards the work of the foundation as helping policymakers, health-care professionals and community groups to understand and address the issues affecting the health of Missourians.
Dr. Kimmey, many people refer to the lack of health access and differences in outcomes as disparities. But I've noticed that you refer to these issues as inequities. Is there a difference between the two terms?
Kimmey: One is the cause and the other is the effect. If the infant mortality rate is three times higher in one population than another, that's disparity. Health inequities are the cause of disparities. That's the difference.
Are the inequities and disparities in the St. Louis area any different from those in other communities?
Kimmey: We're similar to many metropolitan areas. I think we're similar to Detroit and Newark. Those are metropolitan areas like St. Louis that, in many ways, are more highly segregated than other (communities). The high degree of separation (between those with and without health care) is all the more striking here because of the health resources in the community that people aren't getting.
Why does that happen?
Kimmey: The first thing that people point to is financial access. People in communities of color tend not to have health insurance or they are on Medicaid or they are single adults. There are a lot of other issues. A lot of the resources in the community, as good as they are, are not in the communities of greatest need. We have these terrific hospitals. We have a lot of clinics, but the majority of those resources are out of reach to the largest components of the communities with the greatest needs.
Are you optimistic that programs in the Affordable Care Act will shore up health care for those residents?
Kimmey: A lot of potential programs could have real hope of addressing some inequity problems and the disparities in terms of distribution of services, better access to insurance and outreach to single adults. Add to that the prevention programs and efforts to make health-care programs more culturally sensitive.
You and others have noted that this law by itself won't solve all the nation's health-care problems.
Kimmey: Dealing with it strictly from the lens of health care is not enough. If you look at it from the standpoint of housing, transportation, the organization of local governments -- a whole variety of things -- people will say, "That's not health." Income maintenance is not health care, but it does have an impact on health. Unless you (address these issues), at the end of the day, you are going to have differences based on race, gender, etc.
Some very interesting studies done in Chicago and Atlanta showed that African-American women with graduate education had worse pregnancy outcomes than white women with the same attainment. So there's something operating there. It's not just education; it's not just the environment. But education and environment have a tremendous impact. And you need to study both of those at the same time.
You've spoken frequently about the new health-care law. Are you confident that the legislation will be allowed to move forward?
Kimmey: The Affordable Care Act is certainly the most important piece of social legislation since Social Security. It establishes a base on which we can build a system. It's not perfect. Right off the top, 28 plus million people aren't going to be covered, so it's not universal coverage. But it does provide the opportunity to expand the number of people who have financial access to health insurance as well as (establish) programs not directly related to insurance but that have an impact on health. So I'm optimistic about the impact -- if it's allowed to work.
Will it be allowed to work?
Kimmey: Whether it will be allowed to work is a big political question. But a number of things in there already have gone into effect. If they change those things now, people would see it as a takeaway. It will make it very difficult politically to take some of those things away.
What, in your view, is the biggest misgiving some Missourians have about the law?
Kimmey: The real sore point has been the individual mandate saying everybody has to have health insurance or pay a tax penalty. I understand why people don't like regulation. On the other hand, perhaps more than 50 years ago, when Blue Cross Blue Shield was a major insurer almost everywhere, they did what was called "community rating." Everyone they covered was in the same pool, and the cost was distributed across that pool. As we got into more and more proprietary insurance programs, where insurance companies tended to cherry pick the people who are (healthiest), we got away from community ratings. And even Blue Cross got away from that.
So the mandate is similar to community rating?
Kimmey: The individual mandate could be looked at as reinstating community rating, where the healthy people and people with severe problems are in the same pool, so the healthy people paid only marginally more than they would if they were experience rated. (Editor's note: Experience rating is when premiums are calculated using the actual claims experience of a group or individual.) But people who are really sick pay less than they would if they were experience rated. It's a leveling effect, but people don't see it that way. They see it as a regulation, big government telling them they have to buy insurance. But in terms of an economic perspective and a health-administration perspective, it makes a lot of sense.
What are some of the potential stumbling blocks even if Washington doesn't change the health-reform law?
Kimmey: Even if the legislation would go forward as it is written with no opposition and in 2014 the insurance provision kicks in, when you look downstream, three things could cause the legislation to fail to do what it was set up to do.
- Not having a health-care workforce prepared and culturally competent and working in communities where people need health care. So the whole workforce issue is one.
- We need to take prevention seriously. So much of the financial savings projected under the Affordable Care Act are based on the impact of the act's prevention provisions.
- Low health literacy across the entire population. This could have multiple impacts in the context of the legislation from the standpoint of how people can make intelligent choices ... how well people follow instructions from their physicians, how well physicians deal with and communicate with their patients. So health literacy is a real tangle. It's a tangle that has to be dealt with.
Do you sense any disconnect between the area's two medical schools and the public in terms of services to some part of the city?
Kimmey: You've been around St. Louis. You know there's a long history. It goes back to Homer G. Phillips and City Hospital closing in the '70s and '80s. A lot of it was driven by the declining tax base in the city, which couldn't afford to keep these institutions open. But the medical schools received some of the blame from the community. When I came here in 1987, there was still quite a halo of negativity around St. Louis University with the African-American community. That has improved. I think both schools are trying -- St. Louis University through outreach activities, and Washington University, largely through Dean (Edward) Lawlor and its efforts in public health, is trying to reach out to the community. But they are baby steps.
How does the Missouri Foundation for Health fit in with these efforts?
Kimmey: Right from the beginning, one of the foundation's policy goals is to improve access to health care for all Missourians. We've put a lot into that in terms of our activities, particularly in planning and policy. But I think there are two challenges of the Affordable Care Act to us as a funder and to other funders:
- How do we work in some areas before the act is fully developed? It goes back to those things that I mentioned earlier. We're (funding) programming in health literacy and in health workforce. We think that those are places where the foundation's investments can parallel governmental investments and private investments. As this legislation kicks in, it will put Missouri and the people who live in our service region in a better position than they would be otherwise.
- It's easy to say the medical schools have lost sight of the community and are not very well connected. We're probably better connected at least in some cases to the community we serve than the medical schools, but we're probably too prescriptive in terms of what our funding goes for and how the programs have to be structured.... When you get to the solution side, what works for one community may not be a solution for another. So we need to find ways to be more sensitive to those differences through our funding.
So you are hopeful but don't think the law by itself is the answer.
Kimmey: We are not going to solve the problems of inequities and resulting disparities by dealing only with the medical-care system. It's a much broader issue; it's things like income security and education and how our local governments function. We've got to begin to think about social determinants as well as the conventional health definitions if we really are going to have an impact on health disparities. We certainly are sensitive to that at the foundation.
The receptiveness in dealing more broadly with some of the issues that affect health is probably as great now as it has been in recent years for the federal government, and it certainly is with us.
This story was written with the assistance of the Dennis A. Hunt Fund for Health Journalism, which is administered by the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.
