POLICY PAPER: HEALTH DISPARITIES

Access to, experience with, and outcomes of healthcare across Maryland varies widely. These differences and disparities are largely driven by social, economic, and environmental contexts related to social determinants of healthand they  create barriers to accessing inclusive, high-quality, affordable, and affirming healthcare. While wealth and income are major drivers of differences in health outcomes, racial disparities persist across all socioeconomic levels. 

Data consistently shows ongoing and in some cases growing health disparities in Maryland, including the impact of COVID-19, maternal and infant mortality, incidence of HIV, and emergency room (ER) visits for substance use, asthma, diabetes, and hypertension. Black people experience higher rates of heart disease, high blood pressure, diabetes, and asthma; a higher risk of death from stroke; and a higher infant mortality rate. Maryland’s maternal mortality rate for Black women is 3.7 times that of White women, and the racial disparity has widened in recent years. In addition, the COVID-19 pandemic laid bare the stark health disparities across the state as data showed significantly higher rates of infection and death in communities of color. While Black individuals comprise 29.8% of the Maryland population, they represent 15.1% of COVID-19 deaths as of July 21, 2021.

Systemic racism is a contributing factor that policymakers, healthcare architects, and medical and insurance providers must confront in order to provide high-quality healthcare to every state resident, achieve healthier communities, and develop a stronger healthcare system. 

It is estimated that the U.S. could save nearly $230 million in medical care costs if racial and ethnic health disparities did not exist.

 

Historical Context

Health disparities are prevalent throughout all of  Maryland’s communities. Maryland’s Office of Minority Health and Health Disparities (MHHM), established in 2004, collects data that highlights differences in health insurance coverage, prenatal care, and mortality rate. Between 2004 and 2008, all racial and ethnic minority groups in Maryland were less likely to have health insurance than Non-Hispanic Whites. During the same time period, pregnant women of color were more likely to receive late prenatal care. The data also show higher mortality rates for Black and Indigenous Marylanders, as well as higher prevalences of cardiovascular disease, cancer, and HIV/AIDS in communities of color. The incidence of HIV for all races/ethnicities has generally declined in Maryland; although the incidence among the Black non-Hispanic population (49.0 per 100,000) remains 2.4 times that of the total population.

Maryland’s only major metropolitan area, Baltimore City, has one of the country’s poorest health outcomes nationally. Black residents of Baltimore experience disproportionately high chronic conditions and other adverse health outcomes. In 2010, Baltimore City’s rate of asthma-related hospitalizations was almost three times higher than the U.S. average and about 2.2 times higher than the average rate for Maryland. In Baltimore, a 20-year gap in life expectancy exists between the city’s poor, largely African American neighborhoods and its wealthier, whiter areas.

 

Policies Addressing Challenges & Opportunities

Implicit Bias: According to a survey of medical schools, 50% of medical students hold underlying racial prejudices. This translates into lower ratings of patient pain and poorer health recommendations. In 2021, the General Assembly passed legislation, House Bill 28, requiring implicit bias training for health care providers in order to obtain a new or renewed provider license (starting October 2022).

Chronic Diseases and Treatment: Heart disease, diabetes, and hypertension are the leading cause of death, disability, and healthcare costs in Maryland, and they disproportionately affect communities of color. Medicaid spends more than $550 million on chronic diseases of which $196.3 million is spent on hypertension and $157 million is spent on diabetes. With the passage of the Maryland Health Equity Resource Act in the 2021 legislative session, the Maryland Department of Health will launch the Health Equity Resource Communities program. This program will provide extra funding for programs, increase access to treatments for  preventable disease, and seek to reduce fatality rates. 

Rural Healthcare Delivery: Rural communities in Maryland lack the same quality care options as urban and suburban areas. Rural communities often rely on a primary care workforce and regional hospitals, but often need to travel to the Baltimore or DC metro areas for major procedures. Transforming Maryland’s rural healthcare system: A regional approach to rural healthcare, a report required by legislation passed in 2016, recommends ten solutions including ways to expand the rural healthcare workforce, improvements to transportation for medical needs, funding economic development, and implementing pilot programs that can support rural community health. 

Maternal Mortality Rate & Pregnancy: Black women have a drastically higher maternal mortality rate in comparison to white women throughout the nation. According to the CDC, Black women are three times more likely than white women to suffer from pregnancy-related complications. In Maryland, the maternal mortality rate (MMR) decreased by 35.4% for white women between 2013 and 2017 but increased by 11.9% for Black women over the same period. The Maryland Maternal Mortality Review 2019 Annual report made recommendations to reduce disparities in MMR that include improving access and coordination of care to one year postpartum, reinforcing screening and support services for social predictors of maternal death, and to increasing training and awareness regarding disparities in maternal health.

Expanding Access to Health Insurance: At the state level, there have been numerous bills introduced to address health disparities. In 2012, the Maryland Health Improvement and Disparities Reduction Act created the Health Enterprise Zone (HEZ) pilot program with the goal of reducing healthcare costs. The HEZ program used funding and resources from the Affordable Care Act to expand healthcare access and eliminate disparities. As a result, more Marylanders have access to health insurance options which vary by  employment status and income. Under the Hogan Administration, the pilot program expired. This program should be renewed and expanded upon to address health disparities across the state.

In 2013, Maryland expanded Medicaid to provide more health insurance coverage to Marylanders with low-incomes and create large reductions in the rate of uninsured residents. With the expansion of Medicaid, as of 2020, 1,296,128 Marylanders are covered by the Medicaid program, marking an increase of 439,831 Marylanders under the expansion, and bringing the uninsured rate down by 39%. Prior to the COVID-19 pandemic, Maryland’s 2020 uninsured population was ~6.0% compared to 10.9% nationwide. Recent estimates by the Maryland Health Benefit Exchange adjust the uninsured rate to 7.1% due to unemployment. 

 

Recent Legislative Initiatives

Numerous bills were introduced during the 2021 legislative session to address health disparities.

SB0003/HB 0123 Preserve Telehealth Access Act of 2021

This bill, sponsored by Senator Melony Griffith (D-Prince George’s) and Delegate Joseline Pena-Melnyk (D-Prince George’s), establishes guidelines for increasing the use of telehealth in the state. It also establishes payment requirements for telehealth providers by Medicaid and private health insurers. Telehealth allows more patients to connect with providers and is touted by proponents as a way to bring more treatment options to rural areas in the state, especially mental health options. The bill passed with bipartisan support.

SB0005/HB0028 Implicit Bias Training and the Office of Minority Health and Health Disparities

This bill, sponsored by Senator Melony Griffith (D-Prince George’s) and Delegate Joseline Pena-Melnyk (D-Prince George’s), requires health practitioners to complete racial bias training before being granted a license to practice. The bill further establishes allocation standards for the Office of Minority Health and Health Disparities in the state. This bill became law. 

SB0172/HB0463 Maryland Health Equity Resource Act

This bill establishes a Health Equity Resource Communities program that seeks to reduce health disparities, improve health outcomes, improve access to primary care, promote primary and secondary prevention services, and reduce health care costs and hospital admissions and readmissions. Communities will be designated by the Department of Health. The bill was sponsored by Senator Antonio Hayes (D-Baltimore City) and Delegate Erek Barron (D-Prince George’s). The bill became law. 

SB0565/HB0309 Data – Race and Ethnicity Information

This bill establishes standards for collecting race and ethnicity data on health systems and healthcare providers by the legislature. The bill will also change the way the state’s Health Care Disparities Policy Report Card is released. This bill was sponsored by Senator Melony Griffith (D-Prince George’s) and Delegate Joseline Pena-Melnyk (D-Prince George’s). This bill became law.

SB0711/HB 944 Growing Family Child Care Opportunities Pilot Program

This bill established a pilot program aimed at improving the supply and ensuring the viability of family child care services in communities with above-average rates of poverty and unemployment.  The bill was sponsored by Senator Nancy King (D-Montgomery) and Delegate Jared Solomon (D-Montgomery). The bill became law. 

SB0727/HB1326 Maryland Healthy Working Families Act Revisions

This bill, sponsored by Senator Brian Feldman (D-Montgomery) and Delegate Kathleen Dumais (D-Montgomery), would have expanded requirements for employers to allow use of earned sick leave during public health emergencies. The bill did not pass.

 

Additional Considerations

Environmental factors such as air and water quality are fundamental determinants of our health and well-being. For more information about environmental justice and health disparities, click here

One way to mitigate health disparities in the state is to address poor health options in specific communities due to  housing segregation. Redlining is defined as the systemic denial and raising of prices on financial services that target low-income Black neighborhoods. Redlining is considered a social determinant of health, being that the financial affordability of resources is limited. Throughout the United States, racial segregation has resulted in higher health risks for people of color than those living in majority white communities. This is particularly evident in Baltimore, where numerous studies and articles have discussed the effects of redlining on Baltimore’s majority-Black neighborhoods.

In addressing maternal mortality rate health disparities the Black Mommas Matter Alliance has proposed policies that state legislatures can take to improve maternal mortality rates. Some of these recommendations include creating opportunities for evaluation and redesign of health education curricula by Black-led organizations and holding existing healthcare systems accountable for delivery of quality, comprehensive, patient-centered, and trauma-informed care. 

Maryland ranks 6th in the country for health care delivery. Maryland has tremendous health care assets; from teaching hospitals and medical centers to the National Institutes of Health, and a large pharmaceutical industry, the state is well positioned to be a leader for other states to follow. 

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