News Health Systems

Bill Introduced in U.S. House to Improve Health Outcomes for Minority Communities

Emily Crockett

Minority caucuses in the U.S. House of Representatives introduced a bill on Wednesday, the 49th anniversary of the enactment of the Medicare and Medicaid programs, aiming to improve health outcomes for communities of color.

Minority caucuses in the U.S. House of Representatives introduced a bill on Wednesday that aims to improve health outcomes for communities of color.

Rep. Lucille Roybal-Allard (D-CA), along with members of what’s known as the Tri-Caucus—made up of the Congressional Hispanic Caucus, the Congressional Asian Pacific American Caucus, and the Congressional Black Caucus—introduced the Health Equity and Accountability Act (HEAA) of 2014 on July 30, the 49th anniversary of the enactment of the Medicare and Medicaid programs.

HEAA has been introduced in six consecutive Congresses, and sponsors and advocates said that the bill has been used as a blueprint over the years for other policies that improve health equity, especially the Affordable Care Act (ACA).

“This bill is the keystone of our national strategy for the elimination of health disparities,” Roybal-Allard said on a call with reporters.

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Those disparities in health outcomes are significant and devastating for minority communities, advocates said. Hilary O. Shelton of the NAACP explained on the call that African-American infants are up to three times more likely to die in childbirth than other races and ethnicities, African-American men are twice as likely to die of prostate cancer, Hispanic women die of cervical cancer at 1.5 times the rate of non-Hispanic white women, and African-Americans and Native populations are twice as likely to contract diabetes.

“Like many Latinas across the country, I was thrilled when the Affordable Care Act became law because I knew it would provide access to quality and affordable health care for many in our community,” said Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health. “But despite these enormous gains, Latinos continue to experience persistent barriers to affordable and quality health coverage, services, and information.”

HEAA has ten provisions to improve and guide federal efforts to improve health equity in language access; data collection and reporting; health-care outcomes for women, children, and families; and funding to specifically combat diseases with a high impact on communities of color such as cancer, cardiovascular disease, diabetes, and HIV and AIDS.

A working group for the HEAA convenes at the beginning of each new Congress, during which hundreds of minority and health advocacy organizations discuss the latest science to update the bill. A letter signed by 325 national and state organizations thanked Roybal-Allard and her Healthcare Task Force co-chairs for their work in introducing the bill.

Rep. Barbara Lee (D-CA) said that in her district, life expectancy can vary by a full 14 years from neighborhood to neighborhood. “In the wealthiest nation in the history of the world, it’s unacceptable that where you were born determines how long you live,” Lee said.

Analysis Politics

Advocates: Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Katie Klabusich

Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”

Despite the pushback, Murphy continues to draw on the bill’s mental health industry support; groups like the American Psychiatric Association (APA) and the National Alliance on Mental Illness (NAMI) back the bill.

Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”

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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.

All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.

Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”

For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.

“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”

“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”

Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.

Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.

“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”

Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”

The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.

In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.

Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.

“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”

Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.

LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”

In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.

“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”

Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.

“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.

While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.

“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”

The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.

In the meantime, Sen. Lamar Alexander (R-TN) has introduced the “Mental Health Reform Act of 2016” (SB 2680) which some supporters of HR 2646 are calling a companion bill. It has yet to be voted on.

Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.

Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.

“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”

Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.

“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”

News Health Systems

Here’s How Hospitals Can Improve Health Care for Trans People

Kanya D’Almeida

Discrimination against trans patients ran the gamut from violence and harassment at the hands of medical professionals or hospital staff to verbal abuse in medical settings, according to the analysis.

A trio of civil rights groups on Wednesday released a set of guidelines to help hospitals improve health-care access and outcomes for transgender people.

The guidance comes after the federal government strengthened nondiscrimination protections for transgender patients under Section 1557 of the Affordable Care Act (ACA).

The final rule to Section 1557—which builds on a history of federal civil rights laws—prohibits the “denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping,” according to the Department of Health and Human Services (HHS). The rule mandates that covered health programs and activities under the ACA “treat individuals consistent with their gender identity.”

Wednesday’s publication serves as a revised update to a 2013 report coauthored by Lambda Legal, the Human Rights Campaign (HRC), and the Committee on Lesbian, Gay, Bisexual and Transgender Rights of the New York City Bar Association on best practices in transgender care. The report’s authors recommended, among other measures, that hospitals adopt nondiscrimination policies with regard to gender identity and expression, and amend their respective Patients’ Bill of Rights to provide for transgender patients, including the right to privacy, and freedom from abuse and harassment based on gender identity.

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New recommendations in the updated document offer tips for appropriate collection of gender identity data—such as accurate pronouns—in electronic health records, and policy recommendations that would strengthen access to hormone therapy, which refers to the use of estrogens or androgens to induce physical or psychological characteristics consistent with a person’s gender identity.

Advocates contend that transgender people face serious barriers to quality and affordable health care: an analysis of the 2011 National Transgender Discrimination Survey of nearly 6,400 trans and gender non-conforming participants found that 19 percent of respondents reported being refused care as a result of their gender identity, while 28 percent postponed or delayed needed care due to discrimination.

Discrimination against trans patients ran the gamut from violence and harassment at the hands of medical professionals or hospital staff to verbal abuse in medical settings, according to the analysis. Respondents to the 2011 survey, which represents the most up-to-date and comprehensive data on discrimination against the trans community, reported being subjected to unnecessary and invasive physical exams, mockery, and violations of their privacy.

About 2 percent of respondents said they were physically attacked in a doctor’s office, while 28 percent said they experienced verbal harassment in a medical setting.

Survey participants reported incidents in which doctors conducted unnecessary pelvic exams, and one patient—whose gender identity was different from their sex as assigned at birth—said a doctor forcibly examined their genitals and discussed the case with other hospital workers in violation of HHS’ Health Information Privacy Act (HIPAA).

Authors of the revised guidelines say that many trans people opt to disengage themselves from the health-care system altogether, rather than endure abusive and insensitive treatment, resulting in poor health outcomes for the trans community.

“Just 21 percent of hospitals participating in the HRC Foundation’s 2016 Healthcare Equality Index (HEI) had specific policies outlining procedures and practices to eliminate bias and insensitivity toward transgender patients,” Tari Hanneman, deputy director of the organization’s Health and Aging Program, said in a press release issued Wednesday.

“This revised publication will go a long way in helping more hospitals adopt crucial policies and practices to ensure that transgender patients are welcomed and treated with appropriate care,” said Hanneman, who authored the HEI, which evaluated more than 2,000 health facilities for the 2016 index.

The revised document offers policy recommendations pertaining to patients’ access to personal items that would help with gender expression—such as makeup and gender appropriate clothing—and other items that assist with gender presentation, including material used in binding, padding, and tucking.