 Good afternoon. It's my privilege to start off the second panel of the afternoon. Before I do that, I just want to embarrass Mark. Mark, turn around. And for those of you who weren't able to join us in San Diego, I just want to let everyone know who wasn't there, that Mark received this year the 2010 Lifetime Achievement Award by the American Society of Bioethics and Humanities. So while we're celebrating many things today in this conference is in memory of Dr. Tullman, who is very influential in Mark's career. So on that note, can we give a round of applause to Mark, who has no idea that I've said anything. So this afternoon's panel is going to be about health disparities and domestic health policy. And our first speaker is going to be one of my colleagues here at the University of Chicago as a faculty member in the McLean Center. And Marshall is a professor of medicine and Department of Medicine here. He received his MD from University of California San Francisco and his MPH from Harvard School of Public Health. And he currently investigates how to improve the care and outcomes of vulnerable patients with chronic disease. And his current project seeks to improve diabetes care and community health centers. And improve access to treatment preferences of older persons with diabetes. He's Director of the Robert Wood Johnson Foundation finding answers, disparities research for change. And today he'll be talking to us about current challenges in reducing racial and ethnic disparities in health care. Dr. Chen. Thanks, lady. And thanks to Mark for inviting me to speak at this annual conference as well as the yearly seminar series. I think truly are the best interdisciplinary seminars and conferences on campus. And so it's great to be a part of the community here. In the program, the title in the program is Current Challenges in Reducing Racial and Ethic Disparities in Health Care. But actually it's more promising than that. We do know some things in terms of solutions. And so the title is amended to Lessons in Current Challenges. And what I'm going to focus on is what we do know now in terms of what can work within the health care system for reducing racial disparities in care. So here's the roadmap for the talk. I'm going to briefly tell you about our Robert Wood Johnson program, Finding Answers, Disparities, Research for Change. I'm going to discuss the conceptual model that underlies our work for thinking about disparity reduction. I'm going to talk about six key components for efforts to reduce disparities. Go through what we know from a systematic review of literature about what works for reducing disparities. Talk about lessons from our grantees. And then I'll end with someone's setup for Eric Whitaker's talk. Talk a little bit about integrating health care system and community approaches. So Finding Answers is a national program of the Robert Wood Johnson Foundation that's based in the University of Chicago. We have three main goals. So one is we give out money. In particular, we give out grants to organizations that are doing evaluations of practical solutions for reducing racial and ethnic disparities in care. We conduct systematic reviews of literature to understand what works for reducing disparities. And then increasingly, we're entering a dissemination phase in terms of disseminating results to encourage health care systems on a regional and national basis to reduce disparities. So we provide information about what works and what doesn't, and then we're creating resources and toolkits that organizations can use in their efforts. So here's our conceptual model. So you can see these two big bubbles. On the left-hand side, you have a person embedded in their community. If they have access to care, they become a patient who interacts with the provider within a health care organization. At the top, you have a policy infrastructure. So the big hammer is financing in terms of Medicare and Medicaid, for example. There's regulation. And so as people in the audience like Preston Reynolds know, one of the key elements for reducing desegregation in hospitals was the Civil Rights Act of 64. You have accreditation. So you have organizations like, say, JCO and some of the training organizations using the accreditation tool as an effort to both incentivize and use the hammer for reducing disparities. And then ultimately, at the bottom, you have these different aspects affecting processes of care and outcomes. So a couple of years ago, Hal Sox, who at that time was the editor of the Analysts of Internal Medicine, invited me to write an editorial. And he said to me, he's actually a good opportunity. He said that, well, I don't want you to write about this particular article in the journal, but basically use the editorial as an opportunity to talk about what you think are the key components for reducing disparities. And so basically I came up with these six different components I want to share with you. So the first is increasing emphasis nationally, which is basically examining your performance data, stratified by insurance status, race, ethnicity, language, and socioeconomic status. For those of you who point to like the details of the health reform bill of this increasing incentive in terms of the collection of race, ethnicity, and language data. The second is getting training for your staff to work effectively with diverse populations. And actually one more point about the first point. The point about the first point is really it basically prepares people to change and improve. So in other words, people don't believe that there are problems in terms of disparities in their own organization practice until they look at their own data. And then when they see their own data and they see the disparities, then they motivate the change. The second point here is getting training for your staff to work effectively with diverse populations. You know, a lot of different medical schools and nursing schools, they have a cultural competency training programs, but it really goes beyond cultural competency. Society for General Internal Medicine, they have a nice paper where they talk about what goals should be for a course in health disparities. And they come up with four different components. One is the existence of disparities, ideologies, and solutions to miss the awareness. Worked in looking at issues of much trust, subconscious bias in trainees and stereotyping, communication and trust building, and then forth commitment to reducing disparities. So we're looking at the University of Chicago that one of our family members, Monica Vela, leads what is perhaps the premier course in the country for medical students on health disparities. And she led a great session for this year's Ethics Fellows discussing training in terms of how do you train trainees to think about disparities issues. I just want to share some of the things that makes her course innovative. So one is that there are self-insight exercises which basically help people understand their own attitudes for disparities and their own potentially self-subconscious biases. There are field trips and basically sessions in terms of the Chicago history of disparities. And one of the most highly rated lectures, for example, was a talk by a historian on disparities issues in the South Side. This is a group disparities project where people work on trying to improve some disparities aspect in Chicago. The reflective essays and discussion basically is a way to basically have people discuss these issues in a confidential but straightforward way. This discussion about individual patient care, like work with interpreters, as well as policy, just like Medicare policy. And one thing she does is that she draws upon an extensive group of instructors, many from the complaint center, who are particularly skilled at discussing challenging topics like ethics and race. So the third key component was making reduction in inequities in care for vulnerable populations and integral component of quality improvement efforts. So when I give this talk outside of Chicago, I show this slide and I ask people, well, who knows who Bud Bilkin is? And to date, no one has been able to identify who Bud Bilkin is. But this audience, I'm sure there are a lot of people who do know. And so it turns out Bud Bilkin is a fictional character. It was created by one of the African American newspapers, Chicago Defender. And there was an annual parade that we're aware of here on the South Side, the Bud Bilkin Parade, which is the largest African American parade in the country. But the reason why I have this slide is that each year in Chicago Medical Center newsletter, there is either this photo or something comparable, which is basically the university presence at the Bud Bilkin Parade. Now, I think community engagement is an important thing and a very valuable thing. Probably a lot of us here in the audience participate in a variety of community health affairs. And many of us get our children involved and at early stage in terms of community events. However, if this was the only thing the University of Chicago was doing in terms of disparities in community efforts, year ago would be the problem. We're going to talk more about this in a moment in terms of how we're integrating efforts at the university with community efforts. But the point is that disparities can't be sort of a marginalized activity. It needs to be a part of all of our efforts to think about quality. So again, many of you in the audience are familiar with the so-called IOM-6, the Institute of Medicine's six pillars of quality that were reported in their book on the quality chasm. What probably many of you are not aware of is that in the past year the IOM has basically revised that framework. And here's the new framework. You see here the first column is basically the new pillars in terms of effectiveness, safety, timeliness, patient and family centeredness, access, efficiency. The other columns show the conflict of here, ventric here, acute treatment, chronic here. What you see on the left here, you have two cross-chain dimensions. Oh, thanks Mark. I thought I was getting sort of the early hook here. But it's actually, what is the, anyway, it's not working here. You see, thanks Mark. Basically equity and value were thought to be in some ways the most important dimensions, which really are cross-chain dimensions, which cut across all those other elements of quality. So thinking about equity and all of our different quality efforts. Four is providing models of care and infrastructure support to enable organizations to improve the quality care for vulnerable patients. And here's where we come in as academics in terms of trying to create these models of care. Fifth is aligning incentives to reward providers from health organizations for providing high quality care for vulnerable populations. And I think that Harold will talk more about that. Let's skip that. Six is allocating more resources for the uninsured chronic diseases. So one of the things I mentioned in terms of finding the answers is that we do these systematic reviews of literature in terms of what works for reduced disparities. And so at this point, we've reviewed over 200 articles for seven different conditions. And we're currently involved in a number of other conditions, including a variety of people in the audience working on new projects. But when you look at, I guess, the 200 articles, it's actually hard to come up with cross-cunning generic lessons. And here's what we came up with in terms of trying to think about these general lessons from the literature. But one was that multifactorial interventions that address multiple leverage points along a patient's capacity of care tend to be more effective if you're trying to improve outcomes. Because basically any barrier along the way is enough to derail an outcome improvement. And because the causes of disparities are multifactorial, the solution has to be multifactorial. Culturally, tailor-quality improvement tends to be better than generic quality improvement. And then there's a lot of evidence for nourishing interventions with multiple business routines and close to tracking and monitoring patients. Part of that is the attention, part of that I think is the case management terms of really looking at all these different aspects will affect the patient. When you look at the pediatric literature, sort of an homage to Lanny here, with asthma care and immunizations, a few more recommendations. It's important to look at the structural aspects of care experience and impact outcomes. For example, a medical home, as an example of a structural aspect. Incorporating families and interventions and integrating non-health care partners into QI interventions. So this next part of the talk, I'm going to talk about a variety of different example solutions. For our finding interest program, we have grantees now from 33 different parts of the country. So our new map would include Florida and Miami, as an example, in Northern California. So we have sort of a diversity of grantees. And one of our charges is to work with another Rodwood Johnson program called Aligning Forces for Quality. And then these little yellow dots you see on the map are two different target communities and states where we're charged with working with these communities to improve care. And reduce disparities. So they include Seattle, Albuquerque, Memphis, Cincinnati, Cleveland, state of Minnesota, state of Wisconsin, state of Maine, Boston, this Pennsylvania area. So a variety of different places. And we look at our 28 now 33 grantees. Here are the common lessons in the wheelchips and examples. One is that knowledge, attitude and interventions are helpful but not sufficient. Disparity and data interventions are helpful but not sufficient. Context and tailoring are critical. And then they import some multifactorial, multi-target interventions. And also the importance of looking at buy-in, incentives, sustainability, and systems issues. So knowledge, attitudes, and data are helpful but not sufficient. Harvard or Vanguard did a cultural competency training program and then disparity report cards where individual doctors were fed back their own quality data stratified by race and ethnicity. The result, increased acknowledgment of disparities but no change in clinical outcomes. Morehouse, health literacy training, health literacy screening. One-third of the patients in their study had limited health literacy. What was the outcome? Again, physicians were more aware of literacy issues but there was no change in the actual clinical outcomes. So these are both examples of where it's important for awareness training. So awareness training, importance for redness change but in and of themselves this type of training and data are insufficient for changing clinical outcomes. So what are some other interventions? Well, for example of a provider system intervention, West 5 is a health center in New York State. Concurrent peer review. Simple intervention. Basically you have one of your colleagues do a second opinion upon your care. It was a show that increased blood pressure, increased medication intensification. There was widespread provider report and it's reimbursable. Provider patient interventions. So the variety of interventions are basically looking at nurse and phone-based peer support. So at Duke and UPenn over the phone medication management, behavior modification, phone-based peer support. It's an example though of where context and tailing are key. So we need an example of telephone. We have two of our grantees where the telephone has worked and two of our grantees where it hasn't worked. And I think a priority would have a hard time figuring out which ones would have worked and not. So the University of Pennsylvania, I already mentioned that one, peer-based phone support, University of Arizona. A lot of rural patients. So just using video telephone conferencing to do sort of psychiatric counseling, long distance through this type of telephone depression intervention. Those worked. It was where it didn't work. Medicaid help plan in Rhode Island. Telephone care management for the Latino population didn't work. Mobile county in Alabama. Self-monitoring, cell phone texting and phone management didn't work. Both of these interventions, African-American, Latino, diabetes, hypertension, two worked, two didn't. So it's an important context in tailoring. Community health workers used the Irvine and worked. Patient activation, empowering patients with a more active role in care, reduced A1C. Choctaw, Indian tribe in Oklahoma. Community health workers didn't work. And one of the issues there was that it's a very verbal culture. And so some of the training that was involved in terms of the health worker intervention perhaps was not adequately adapted for that particular culture. Massly the community health centers in Massachusetts. Health workers didn't work. Patient intervention. So one of our best ones is Cooper Green, which is the Strozer Hospital of Birmingham, Alabama. They have patient narratives on DVD looking at a variety of hypertension issues. Giving this DVD out to patients, randomized control trial, lowered blood pressure. A variety of incentives. So Baylor is testing a P4P nationally in the VA system, SIGNA, Patient Incentives for Office Visits. Erin E. Henry at Health Center in the Delta in Mississippi. Patient incentives for reaching weight, exercise, and medical. And here's the goal. These are in progress. We don't know the results yet. But again, to show the variety of type of incentive interventions which are being tried. So again, to summarize, less necessarily grantees. Model interventions are necessary. But once it needs to be tailored in a specific situation, interventions have to be intensive. Knowledge and data are insufficient. Multi-factorial, multi-target interventions are the way to go. It's crucial to look at the process of intervention and the process of implementation. And the importance of looking at buy-in incentives, sustainability, and system. So this is my last slide. And again, a setup for Eric that increasingly in our work here in Chicago, we've come to the realization that it's critical to basically integrate what we do in the healthcare system for these disparities with work in the community. We're doing a lot of work with diabetes in particular. And we think that the cutting edge really is this interface in terms of bring the strengths and assets of the community to the strengths and assets we bring within the healthcare system. And I know Eric will talk a lot more about this. So we look forward to the discussion. Thank you. Like the first panel, we're going to take all questions during the Q&A. I'm actually going to change the order because Dr. Whitaker has another commitment and I just want to make sure that we get to hear at least his talk and hopefully we'll be able to say for part of the Q&A. So our next speaker will be Dr. Whitaker. Eric Whitaker is the executive vice president, strategic affiliations, and associate dean of community-based research at the University of Chicago Medical Center. He's walking up here because I had to promise I would keep the introduction short. Today is responsible for leading the University's Urban Health Initiative, linking the Medical Center mission of patient care teaching and research for the purpose of improving the health of the Southside residents. Dr. Whitaker graduated Grinnell as an undergraduate. He graduated the University of Chicago Medical Schools and then went on and got his degree in public health from Harvard University. Until 2007, he served as director of the Illinois Department of Public Health and we are thrilled that he has come back to the university as our executive VP. Thank you. It is a pleasure to be here once again at the McLean Fellows Symposium. It's been great to be among many of my mentors and role models. Gene Washington left and I didn't get a chance to tell him. He was suggesting that staying at the Quadrangle Club was a bad thing. In fact, while I was sitting up there and he was talking, I got a text from Chicago Crane's business that the Four Seasons in fact had a fire. So it was a win-win-win for Dr. Washington and he didn't know it. I want to thank Dr. Siegler for the invitation to be here today. I want to also thank him for inviting Urban Health Initiative to be a part of the seminar series for this year. I think we've had probably about five or six. There will be a total of 28 or 29 lectures looking at health disparities and we've been excited to be co-hosts with that process. So I want to thank you, Dr. Siegler. In fact, Mark was my first attending when I was a third year medical student and has had an impact on me since that time. So what I have to do in a very short amount of time is to give you a sense of some of the work that we've been doing here on the South Side of Chicago. And you all probably know this famous jurist, Judge Judy. And given the limitations on time, I wanted to have us stipulate some things much in the legal manner. One, I think the speakers who came before laid a lot of the foundational work for these stipulations first, that in health place matters. Where you're born is something that's important. Also, it's from all the work that's been presented before that health status is due to many things beyond the healthcare system. And I agree with Dr. Washington that it would be generous to say 20% of health is from healthcare. And the last one gets at the fact that often when we talk about urban communities, when we think about urban communities, we often think about them from a deficit model. And it's our belief that to improve health status on the South Side of Chicago, we have to pay attention to place. We also have to look beyond the healthcare or medical model and look at other social factors. In fact, as a physician and a hospital administrator, I'm talking to grocery stores about citing themselves on the South Side of Chicago as a way for economic development and alleviating food deserts, which is something using that in a hospital administrator's job description. But we think it's an important thing to do if we're to improve health. And lastly, as Marsha mentioned, there are a great many assets in the community and it would be wise of us to build on those assets to try and improve health. And one of the assets that's often underappreciated is actually human assets, the knowledge of the people who live in the communities. And just by way of introduction, we call the South Side the darkly demarcated line around the 34 community areas. And it constitutes in our way of thinking about 34 of the 77 community areas in the city of Chicago. This is about 1.1 million people, largely African-American, about 72% African-American. And it spans all over the terms of income status across the African-American community. We also within the borders have a Chinatown as well as an area with a largely Latino population called Eastside. And I probably should have had a fourth point to stipulate that on the South Side of Chicago in our primary service area, we have a lot of death and disease. You know, if you look to the right, the infant mortality rate for Chicago is about 0.9. And as you can see, those red communities are, you know, with community areas with an infant mortality rate that's higher than both the city and the Illinois average. To the left on the slide, for a number of chronic diseases, heart failure, diabetes, kidney failure, asthma, hypertension, the hospitalization rate on the South Side of Chicago is two plus times that for the state of Illinois as a whole. So, you know, we have a lot of chronic disease and people end up in the hospital for that chronic disease. So this thing called the Urban Health Initiative, what we are trying to do is to build a health ecosystem where one doesn't currently exist, disorganized, and do so in an economically sustainable way. When I started medical school at Pritzker in 1987, we had a number of hospitals on the South Side of Chicago. You know, fast forward to today and we have about seven less hospitals on the South Side than when I started medical school here. And we also believe that if we're to do well in terms of health status that the community has to be engaged in the process, not have research on the community or, in fact, we need to have community fully engaged in conceptualizing research, carrying it out and helping to interpret the research. We are very mindful we're a research institution and in fact we believe in a number of different domains and the research and development is a critical thing if we're to advance science and improve and in fact develop scalable urban models. We also, as a University of Chicago in our medical school, we're the fourth leading producer of academic physicians in the country. And if we do this well, we'll be able to have a multiplier effect across the countries and medical schools all over the U.S. And lastly, much to the work that Marsha's been doing, we want to help create and learn from other models and create new models that can be used in this country and in fact throughout the world. And we've talked about systems, science and service and trying to develop the research in all of these elements. First, in terms of the systems, we have created something called the Southside Health Care Collaborative that builds on the work of First Lady Michelle Obama, who at the time she was here, maybe about six years ago or so, started a collection of community health centers. There were 18 at that time that was trying to find medical homes for the 40% of patients in our emergency room who really should not have been in our emergency room but had primary care problems. That effort has grown to now 33 community health centers and five hospitals. So on the Southside of Chicago, we have all of these individuals around one table talking about quality, talking about access to subspecialty care, and to the extent that electronic health records gets rolled out, we will be able to have a health information exchange area where we can learn lessons from the patients who are in that system. Also, in terms of science, Dr. Stacy Lindow heads a family of studies that's called the Southside Health and Vitality Studies. It's population-based research, and that will be the backbone for us to assess the changes as we try to determine how our interventions impact health or not. And lastly, in terms of translational science, once we have data that we generate or data that others have, we believe we can work with community to translate that research into impacts at the local level. Importantly, on the one hand, the Southside Health Care Collaborative is about health care, and the Center for Community Health in our vision is about other things that I would call more public health in nature, economic development, jobs, education, housing. Again, that complement to the health care that leads to a healthy, vibrant urban community. Again, we're attempting to have a 360 approach to health and wellness. The social determinants are important if we're to do that. We're very mindful that this builds on the pillars of an academic health center. In fact, one of the points that Marshall made is one that we've internalized, that we have to be a part of the fabric of the academic health center, and not some community affairs thing that when budgets get tight, it gets cut off. So we're built on patient care research and education. In terms of patient care, we now have our doctors out in a number of settings. I talked about the Southside Health Care Collaborative. We have our physicians and some of our medical students and residents now doing training out in various community health centers. We have a medical service at a community hospital where the internal medicine department as well as the psychiatric department, psychiatry has a lot of effort at. We also at a community level have a subspecialty hub that's fairly unique in the country where we have 14 subspecialists who see patients on a community base out in the community. And we're currently attempting a fashion relationship with Providence Hospital, which is a part of our public system. Our patient advocates work to link patients throughout the Southside at the site that makes the most sense for both primary and subspecialty care. And again, we believe there's a lot of promise with electronic health records as it relates to continuity of care and quality. And this just gives you a sense of the breadth of the relationships that we've established over the last four years. We're a research institution and it is an important thing to do to understand what's going on on the ground. And hopefully we can start getting the causal relationships and get beyond the correlations. Importantly, the community has to be a full partner in that process. And as I mentioned through the Center for Community Health and Vitality and the Southside Health and Vitality Studies, our community has a place at the table. We also believe that when you find out things through the research, we in fact need to go and report out the results that we might have. And that we approach all of our research with community benefit at the forefront. In terms of the Southside Health and Vitality Studies, we have three major domains that we're working on now. We have asset-based mapping that's going on, the so-called environmental mapping. We have students and others walking the streets to figure out where the parks are, where the churches are, what buildings are there, what services are available, and how the built environment exists as well as what sort of technology is available. And we're in the midst of planning a population-based study that learns from the best of population research around the country. And lastly, one of the things that I think a lot of people are excited about, and a term that has been called data collaboratory, where we take any data that exists about the Southside and curated in a warehouse so that our community-based organizations and others can tap into it. And we help facilitate the use of that data so that the data, you know, the researchers don't use the data and then put it on a disk or in a file and forget about it. Education is the third part of the mission. And we are, for the first time, in a robust way, getting education out in the community with our docs, as I mentioned earlier, having medical students out. And I don't want to oversell the Office of Community-Based Education. There's only one person in that right now. But, you know, we're moving in the right direction to pay attention to how education happens on a community-based. Medical student debt is a big, big issue. I think our indebtedness for medical students on average is about $170,000 to $180,000 a year. I mean, humorably, I should say. And we have a program called the Reach Program where we will pay up to $40,000 a year for each of four years or $160,000 if our graduates practice in our network on the Southside of Chicago. For both primary care and subspecialty care. So we have three individuals who have taken advantage of that, and we hope to expand it as we go along. The Center is an exciting new initiative that we have. And again, the premise there is that there are a lot of assets in the community, and we need to be asset-based focused. It is the face of our project out in the community, and for both research and education, and again, making research accessible to community partners and encouraging their participation. But not only having data, but making sure that the data is actionable and we can change policy or create programs and evaluate them for impact. We've employed a lot of individuals in our research, and we've partnered with groups that are nearby who are there to create employment opportunities for community members. And that's been a nice collaboration with a group called CARA that's in the neighborhood. I'm running out of here because I'm going to our community grand rounds, so my team is sponsoring community grand rounds tonight on community violence prevention. So that's why I'm leaving here. We had our first community grand rounds last month on mental health services where the community members participated in a play about mental health. And we brought the best evidence to bear in terms of mental health, and we did into a play and also had experts in mental health there to participate in a question-and-answer session. This is part of the CTS funding that we have at the University of Chicago, and we have a number of community partners who are part of that. All of the topics that are on the right side, mental health, community violence, interpersonal violence, asthma, health issues for seniors were all of the ones that you see on the right were chosen by community members and not by our researchers. So this is what they wanted to hear about. Just to give you a model, as you can see the center and the studies, and importantly, the residents are in the middle of all of this. So again, if we don't have the residents, we need not be doing the rest of this. This is Dr. Stacy Lindau, one of our colleagues who went to D.C. with a group of physicians in December, not in a political way. It was a nonpartisan group of doctors who just advocated that health performed some type needed to happen. And I put this up just to amplify the work that Dr. Washington talked about. We think there's a great deal of potential for the Urban Health Initiative with healthcare reform related to community health centers, related to prevention, related to health professions workforce, and we hope to really take advantage of that. And I'm closing out by saying that we've had a rocky couple of years when our work got wrapped up into presidential politics. These are a number of the headlines. And I do want to say if you get called by Rush Limbaugh, Glenn Beck, or the like, just say no. Don't call them back. It's not worthwhile. And now that we've emerged out of the presidential race, the Chicago Sundtimes in March 2009 and more recently the Sundtimes here in Chicago actually said this work is important and something that's worthwhile and should be doing and should be a model. Now in terms of lessons learned, community trust is a big thing. And I've spoken all over the country to universities and there's often town down sort of problems with the community. But one of the things that we've learned is that if you have that trust, which is hard earned, it can withstand many shocks, even if you're in the paper and bad things are being said about you. But it requires continuous communication. And we were benefited by the fact that we built our well before we needed to drink from that reservoir and it worked well for us. It also helps that we had a team that's credible to the community and the community leaders and others felt were representative of the community and therefore allowed us our work to move forward. We believe in transparency in all of our work. In fact, you can go on our website and find the minutes for nearly every meeting that we have so that those in the community can know what's going on. And I found that by using all of our assets, not only the intellectual assets of our medical center and our business school and our policy school, but using assets like our political assets where we went to lobby on behalf of hospitals and community health centers where we didn't have a direct benefit. You know, people appreciate that because as the University of Chicago, we do have a lot of assets. And lastly, we have a lot of financial capital that we can fund things and support things in a way that others. And lastly, we've learned that giving credit to others is an important thing and that the University doesn't always need to be at the forefront of things. So, you know, as I close, I just always need to thank the funders and there have been a number of them. I was at the double AMC meeting on Sunday and went to HHS on Monday and met with a number of leaders and who implement healthcare reform. And at the double AMC as well as at HHS, they're excited about the infrastructure we're building. The thing I will say is that there's no quick fix to this. This is going to be a lot of tough sledding and hard work over one, two decades and we're in this for the long haul. And I'm excited about seeing the results. And if we're lucky, you know, we will make the impact that we think we can. So thank you for considering this and I hope I'm around for questions and answers. Thanks a lot. Speaker will be Professor Harold Pollock. Dr. Pollock is the Helen Ross Professor at the School of Social Service Administration and faculty chair for the Center for Health Administration Studies. He's also co-director of the University of Chicago Prime Lab and an associate director of the Clinical and Translational Science Award. And most recently he has joined the faculty of the McLean Center. Harold is a graduate in electrical engineering and computer science from Princeton and got his PhD in public policy from Harvard. He has published widely at the interface between poverty, policy and public health. Before coming to SSA, Professor Pollock was a Robert Wood Johnson Foundation scholar in health policy research at Yale University and taught health management and policy at the University of Michigan School of Public Health. Please welcome Dr. Pollock. I actually, in a sense, I tore up my intended presentation in light of last Tuesday's election. You may not believe me, but I actually did prepare for it today. And those of us in the room who supported the Affordable Care Act, health reformer, might have been disappointed by the Tuesday's results. Others of us might have been less disappointed. This being University of Chicago, I think we have both sides well represented. Whatever side you're on in that political dispute, I would say two things are indisputably true and color the way our health policy debate is going to go for a while. First, we're living through hard times. We really are. A widespread and chronic joblessness at a level that we haven't seen in decades has shaped everything in American life within the past couple years. 47 states are in significant financial difficulty. And the state and local budget crisis is the most critical factor in the mechanics of health reform and in the capacity of state and local governments to implement the responsibilities that they've been given in a very ambitious piece of legislation. Many states are laying off teachers, police officers, firefighters. Kane County, Illinois, close to us, is laying off half of the public health department. We are, you wouldn't know it from the rhetoric in the midterm campaign, but more than 50 million residents in this country lack health insurance and that number is increasing. On my own street, there are 22 houses, five of them are empty. An organization that serves my disabled relative is in financial distress because the state of Illinois isn't paying its bill. There's a waiting list of 21,000 developmentally disabled individuals in Illinois who need services. This is the largest agency in the south side of Chicago and the south suburbs. It's taken eight new clients in the past year from its huge waiting list because there's just no money. That's the context in which public policy is occurring at the moment across the country. Now second and no less true, we're genuinely blessed in a different way to live in a moment where real history is being made right in front of us. We often tell our students about the New Deal, the great society, moments of historic upheaval. We're actually living in one of those moments right now. I know history is always being made, but rarely so obviously with the intensity that it is right now. Whether we're referring to the election of the first black president, the passage of health reform, gay marriage, medical marijuana, the rise of the Tea Parties and Sarah Palin, a field mouse eating an owl, the Cubs winning the World Series, lots of unexpected things seem to be happening, and just a lot of stuff is going on. That makes my assignment today, my talk title is making it to 2015 especially difficult. I feel a little bit like the foreign policy experts who are asked to comment on the Israeli-Palestinian dispute. I think we have a pretty good idea of what it might look like in 2030. What it's going to look like in 2013, no one has any idea. I think that 10 years from now the United States will have substantially fewer uninsured people than we have now. We'll have expanded Medicaid eligibility or something equivalent for poor people. We'll have health insurance exchanges or something very much like them in the lexicon of health reform that offers moderate income people financial support and regulatory protections that are somewhat like what those of us who work for large employers enjoy right now. So in the long run we have some understanding of what the contours of the American health system will be. How we're going to get there is a real mystery. Before 2015 we're going to have two elections. We may have President Obama, we may have President Palin. Some safety net providers within the short bicycle ride of this building will probably go out of business before 2015. Others will expand. Eric's going to be busy. I think we're in for a wild ride. And it's going to be a wild ride in a time of fiscal crisis and political gridlock in the short run when the most difficult implementation challenges in our health care system will have to be resolved. Hank Eyre and not the baseball player, the health economist, they're different people, noted that health reform has created some of the largest bureaucratic challenges in American history and it requires a sense of bipartisan goodwill to resolve them. I would say that with 100% accuracy I can predict we will not have that bipartisan spirit of goodwill when a lot of those decisions are made and this will be a real challenge. I'll give you some predictions today about what I think will happen and the irony of what I think is the most likely path that we're likely to be on. Ironically there's a kind of self-fulfilling false prophecy that's playing itself out. Republican and conservative Democrats caricatured the health reform bill as a costly and undisciplined beast and if it comes to resemble that caricature in the next several years, ironically it will be because those very same critics are going to work hard to attack the elements of the Affordable Care Act that annoy interest groups and that constrain medical costs and I think that both Democrats and Republicans face some very serious dilemmas over the next couple of years and the most likely outcome is that some of the elements of health reform that are most aimed at constraining cost growth and disciplining the system are going to be the first ones that are likely to see eroded. Now what are some of the dilemmas that Democrats and Republicans face? Democrats face the reality that they just lost their majority and in search of a politically feasible and ideologically moderate reform they passed a very organizationally complicated one that the public doesn't seem to like or understand very well. Democrats also bear the burden of just owning a catastrophic economy and this is not a talk about economics and politics directly but those obviously cast a long shadow. Now Republicans have their own dilemmas which people don't think about quite as much. I doubt that they're going to be able to or will choose to smash the central pillars of health reform over the next couple of years. If you ask Americans do you like health reform? Sadly for Democrats the answer tends to be no not very much but if you ask people about the specific provisions of health reform each one in isolation tends to be pretty popular and the ones that are unpopular tend to be the things that are in there so that the popular ones can actually happen and so this creates a real dilemma. So we're very likely to keep protections for people with pre-existing conditions health insurance for young adults, expanded coverage. These measures are really pretty popular in American society and I don't see any real evidence that Republicans are trying to construct an alternative that would really get rid of those things. Now to keep those things the Republicans face the dilemma what do you do about the individual mandate and some of the other elements of health reform that are actually passionately opposed by the Republican political base and passionately supported by some of the interest groups that are very central elements of the Republican coalition. So if I really don't envy John Boehner right now I think his complexion may turn from orange to white as he tries to manage the collective action problem that white isn't pale about to pass out not white isn't Caucasian. So Republicans have some real dilemmas in what to do. There are some clear non-starters that right now are being talked about in the press that I think we can save a lot of time in getting a chuckle and then moving on. And let me say a few things about Medicaid is one of those issues. The Affordable Care Act extends Medicaid to every American with an income below 133% of the poverty line. I'm a public health researcher I don't think most Americans appreciate this is a fundamental improvement in our public health infrastructure that we've made Medicaid an income-based program. And this is going to be very hard to undo and very important. Now why is this so important? Medicaid right now is a means-tested categorical program that's the kind of language that immediately causes a layer of narcolepsy to extend over the audience. You have to be a certain kind of poor person to get Medicaid. You have to be a kid. You have to be a welfare recipient. You have to be on SSI. And many poor people with the greatest public health concern are just not eligible for Medicaid. Let me give you an example. Suppose that you walk past Medici's today on the way home and there's a homeless man who has a drug problem who asks you for a couple dollars. He's not a veteran. He's not a mom. He doesn't have a qualifying disability since substance dependence is not a qualifying condition for federal disability programs. But he might need something like methadone treatment to deal with his addiction. Who's going to pay for that treatment? Right now that treatment is paid for through a patchwork of state and federal funding streams that really are stressed because of the state and local budget crisis I just mentioned. And that also don't cover the fact that they have some physical health problems that also need to be addressed. Every now and then you come across someone who says, I just know about the drug addicts who just don't have any comorbidities. And my reaction is, oh, that's where they are because I never see those people. Most of the people that I see have mental health issues, have physical health issues. So expanding Medicaid flash forward to 2015 and you think about that same guy. Now he shows up at the methadone clinic and they enroll in Medicaid. And Medicaid pays for substance abuse treatment and they can send them to the psychiatrist and to the person to look at his foot problem and it's still covered. That's a huge change. Now emboldened by last Tuesday's election, some politicians around the country are talking about having their states withdraw from the Medicaid program. Texas is the one where the governor and some of the leading politicians in the state have talked about this. Now I must say, were it not for the likely human consequences of the attempt, I would say that liberal Democrats are hoping that they tried this. This is so politically, economically, and administratively ill advised that I think the term self-immolating would be a good description of the political strategy behind that. And let me say a few things about that. In pure dollar terms, right now the federal government pays for 70% of Texas' Medicaid program. Now some of that is because of the stimulus, but in normal times, the federal government pays for more than 60% of Texas' Medicaid. And in fact, the federal government will pay virtually the entire tab for people made newly eligible for Medicaid under health reform. Now what makes Texas nervous are all the people who are eligible right now who are not being served but who might sign up for the program. And that's a fiscal issue that the state has to face. But if Texas withdraws from the Medicaid program, they somehow would have to explain where the $24 billion they're now getting from the federal government, how they would replace that. There's some people who claim that they found a way to make the budget numbers work, which seems highly doubtful to me. But even if they could, balancing the budget is only one issue in play. Medicaid is hardwired within the payment systems and the financial model of not only thousands of medical providers but also nonprofit agencies, schools that provide Medicaid-funded services and more. And if you withdrew $24 billion from this ecosystem, no one can say exactly what would happen except the one predictable consequence would be you would provoke the most determined backlash from a highly organized group of very unhappy people. And one more thing that's pertinent, when people think about Medicaid, they tend to think about poor people, right? You tend to think about in Texas, who do you think of as a Medicaid recipient, a poor kid, maybe a child of immigrants. You tend to think about politically marginal people when it would be sad if those people were hurt by budget cuts but you sort of think of those as people as relatively marginal in American politics. And that's because we have a level of cognitive dissonance if you ask Americans about what we think about government. At the most general level, we are very strong believers of unlimited government. At the same time, we actually support particular programs that serve ourselves and the people that we want to help. And it turns out that 60% of the dollars that the Texas Medicaid program pays goes to the elderly and to the disabled. And so you might expect that withdrawn from the Medicaid program but ineffective protests from traditional Democratic constituencies and some other rather weak groups. I think some of those legislators might suddenly get to meet some surprisingly angry good old boys who are wandering in and asking, hey, what happened to the nursing home that's taken care of my mom? And how come my cousin's autistic child suddenly can't get services at the local high school? And these guys are armed. This is Texas. We don't know. So one of the challenges that the Republicans face is a lot of the things that are in health reform in terms of the numbers, maybe helping a lot of poor people, but in terms of the dollars are helping a lot of the people, maybe not the people in this room, but people that are surprisingly close to a lot of the people in this room. And so if you try to constrain those programs for better or for worse, you discover that there's a powerful monoclass constituencies behind it. So that's a long way of saying a lot of the things that the Tea Party folks are talking about right now are really not going to happen once the immediate euphoria of their victory fades. Now what will happen? Instead of something that drastic, I think two things are likely to happen. One is there'll be lots of hearings in the House of Representatives and we'll get to find out all the embarrassing things about health reform that the administration is not doing well that can be investigated. And second, there'll be an effort to try to erode the elements of health reform that are not that popular, particularly the things that were put in the bill because they needed to get the budget numbers to work. Which brings us to another irony, which is the demographic transition that's happening within both American political parties. The Republican political base in the midterms was pretty much senior citizens who voted for Republicans by 20 points. And so one can imagine the House of Representatives making some pretty serious attacks on some of the elements of health reform that curb Medicare advantage and some of the other elements that seniors are not fond of. Perhaps the Cadillac Insurance Tax and the Independent Payment Advisory Board, this is the alphabet soup of health reform. But there are basically things that are the medicine that you have to take to make health reform work. And it's kind of a sad lesson not just for Democrats, but actually for a lot of the Republican policy wonks which is that paying for stuff in general is not a good political strategy. Medicare Part D which was the previous big health measure imposed an unfunded liability larger than the social security system and it's pretty popular. Health reform reduced the deficit but it did so in ways that got people pretty upset and a lot less popular. And so I think that's a sad lesson that is bipartisan. A lot of the elements of health reform that are unpopular are things that Republicans favor as well as Democrats. Now let me say some things about political sustainability. I actually think had the framers of health reform thought about political sustainability with the same diligence that they thought about a lot of the policy wonkery. We would have had better politics and probably in the end crafted better policy than were likely to see. It's not that I think that people were naive and that led to designing a bill that was unpopular which led to the midterm defeat for the Democrats but I think that Democrats might have predicted that that midterm defeat was coming and designed the bill in a way that could have weathered the storm better than is likely to. I'm now reading there's a terrific book by Eric Ptachnik called reforms at risk which talks about what happens to reforms after they are passed and why are some sustainable and some not. Some of the issues are obvious. Health reform is very back loaded. It does not create an immediate visible difference in enough people's lives to create enough political momentum for it right now. That's going to be two elections before it really does affect the daily lives of millions of Americans the way that once it does will make it a permanent feature of American life. Right now the activities under health reform are about 5% of what they will be in six years. So a lot of the stuff just hasn't happened yet and people don't see whether it's a good thing or not. For example there's a program for pre-existing conditions which has been funded for $5 billion from now until 3.5 years from now. And it turns out that the need for this program is probably 3 or 4 times what's been budgeted in that program. So the back loading was a serious mistake. I'll also note that there's some other things that are less obvious than the back loading. By the way if they had put more money up front it also provided some stimulus to the economy which might have been nice. We've seen all these state and local employees being laid off who could be doing things to improve public health. That's just to keep you awake. And I think that's really too bad because a lot of the provisions are really so important. I mentioned the Medicaid provision. There are many others I don't have time to discuss but I'll just simply say that health reform is the most important policy. It's more important than any AIDS strategy ever published in America. It's the most important drug policy, which is pretty low bar, but it's more important than any drug policy ever published, illicit drug policy that is in the United States. In terms of disparities, Marshall mentioned disparities. There's some accumulating evidence that universal coverage would be very helpful in reducing some of the key disparities. It won't reduce all the disparities because there's a difference of health that health reform can't address. Kids are getting shot in the city of Chicago right now, giving people Medicaid cards is not going to solve that problem. But a lot of the basic issues in cardiovascular health turn out to be it turns out that universal coverage is very helpful. 30 years ago the Rand Health Insurance experiment gave some people free health care and some people the equivalent of a catastrophic health care plan. And the poor people in the free care had a 38% lower mortality rate. And the basic reason for that was that they had better control of their hypertension because they went to the doctor more often. If you hurt your knee and you go to the doctor, your doctor's probably not going to help your knee much. That's sort of the dirty secret of medical care. But it will take your blood pressure and that's a good thing. And similarly people have looked at race, ethnic, educational disparities in the Medicare program. What happens to people when they go from age 62 to age 63, 64 to age 65? And it turns out that there's some pretty dramatic reductions in racial disparities in basic measures. Cystallic blood pressure, racial disparities drop by 60% at age 65. Disparities in blood glucose control and diabetes decline by 75%. Educational disparities in total cholesterol become negligible and some of the Latino white disparities actually start to flip and you see a favorable impact where Hispanics have better indicators than non-Hispanic whites do. And the Medicare program is not a particularly well-tuned program for prevention, but it does get people into the doctor. The new law will require insurers to cover without cost sharing, evidence-based preventive services. I'll just, it's late on a Friday so I won't go into a lot of detail, but I'll say that there's this thing called the U.S. Preventive Services Task Force. How many of you have heard of the U.S. Preventive Services Task Force? How many of you raised your hand just because you wanted me to think that you're smart? So the U.S. Preventive Services Task Force it turns out that any service that gets an A or a B rating from this group of experts has to be covered by insurers without a co-payment. And what's remarkable about that is a lot of the services that we in the public health community fought for actually have good ratings from the Preventive Services Task Force. For example, screening for alcohol disorders in the emergency room. It turns out that's been hard to get insurance companies to pay for, but it has a B rating. So now the insurers have to pay for it starting in 2011. What's interesting about that is we don't have to litigate these anymore on an insurer-by-insurer basis or issue-by-issue. It's an organizational change that says this organization, the Preventive Services Task Force which is empowered to make public health policy in a way that's pretty entrenched. Now contrast that to something that was less politically adroit which is there's a nice new prevention and public health fund which I and others were very happy to see funded. It turns out there's $15 billion in this fund over the next decade. We were very happy about that. There's one problem with that which is that it is solely dependent on congressional appropriation. If you want to make something permanent you cannot make it vulnerable to the whims of a future congressional majority. This is exactly the kind of provision which is most likely to be cut. In fact already in the last Congress there was a Republican measure put in to eliminate this fund and to use it to finance a measure that would reduce paperwork on small business. I can't read what that says. So let me finish on a positive way which is we spend a lot of time in public health saying how can we come up with good arguments that convince people prevention is important. The truth is we've already convinced people prevention is important but the good arguments are not really what we need. We need to create constituencies and interest groups and organizations that will give some momentum behind the things that we do. Moving forward to 2015 we have to find ways to entrench what we do in a more sustained way. We've done that with tobacco taxes by the way because states need the money but we haven't done that with some other things. And I think if there's one positive element right now ironically it's that Republicans have won a lot of state houses in America. I think that President Obama and Speaker Boehner have a very hard time finding ways to cooperate but I think there's a lot of Republican governors who have some common interest with President Obama looking forward who really have a stake in health reform working and if I were to bet my money on where bipartisanship in the next four years will be most surprising and most successful it will be in the partnerships that the President and Governors can create to get this done to deal with a state and local budget crisis to transfer some money to states that need it and to create a platform that will make this reform successful. So I'll stop there but thank you very much. Our last speaker for the panel is Dr. Preston Reynolds. Preston is Professor in Geriatrics and Palliative Care in the Department of General Medicine at the University of Virginia. Preston has served as Holstein faculty at Johns Hopkins University, University of Pennsylvania and Eastern Virginia Medical School where she held the position of Chief of General Medicine Center for Generalist Medicine. Preston's area for research for more than 30 years has focused on the history of race discrimination in healthcare and medical education. She has published and lectured on the subject, received major funding from the NIH and other national foundations and won awards for her scholarship. In 2010 the American College of Physicians honored Dr. Reynolds with the 2010 National Advocacy in Healthcare Reform. It's my pleasure to introduce Dr. Reynolds. So, I'm going to share with you why I was so passionate about Reauthorizing Title 7 what I thought the promise of it was and I'm going to leave you with some concerns because it's me. Because I am concerned that the promise of health reform will not be realized and I'll tell you why when we finish. And part of this is having direct experience advocating for many of the provisions of the ACA post post voting post success. So, let me start. As you can see health disparities are one aspect of the quality crisis in the United States and other countries without question outperform us on every quality measure. As you can see, Canada rates fifth in terms of equity largely because of the denial of access to services to their indigenous Indian population. This country has a legacy of discrimination in healthcare and I think if we fail to remember that we will fail to achieve some of the goals that our earlier speakers spoke of in terms of health equity and justice. But denial to training was really the reality of African Americans until the mid 50s 60s and early 70s. It was a problem not only in the south. The first medical student, black medical student was admitted to the University of Arkansas and not until 1948. It was not until 1963 that Duke admitted its first black medical student. So, denial training for nurses, dentists, physicians was widespread throughout this country. More extreme in the south and in the north, but it was prevalent in all regions, in all corners. But race discrimination did not only happen in health professions training, it also happened in access to health services. Blacks were absolutely denied care even under emergency conditions in Chicago hospitals, Birmingham hospitals, Tuskegee hospitals, hospitals all over in this country. And if they were admitted they were admitted to segregated basement wards, attic wards, separate buildings often that were dilapidated, worn out and underfunded. And this really didn't change as Marshall had teed me up. This really didn't change until the regulations to implement Medicare were put in place under President Johnson in the summer of 1966. Really, I could argue one train of thought which is overnight, the racial template of American medicine and health professions training changed, but in reality, I took another decade for the regulations to really become embedded. That was then. This is now. And I want to ask you to think about this question. What skills will clinicians need to care for the next generation of Americans who already reflect far greater diversity in the current mix of health and health? 2010 census data was talked about at the recent AMC meeting that Eric talked about by the new CEO of diversity of the AMC. And as he said, cohort of Americans under the age of 18 already 25% report high health illiteracy, 32% report being in the lowest income group. And these youth are predominantly Hispanic women. Title 7 has been dedicated to really promoting primary care careers. Why is this important if we have a conference on health disparities? I think the data is irrefutable that primary care workforce reduces health disparities. The data is becoming even more clear that when care is delivered in the patients under medical home, disparities are, they just don't exist. So, primary care physicians compared to specialists, and at the same time, there's improved quality with lower mortality and lower morbidity. Why increase diversity? Well, we know from the data that underrepresented minorities are more likely to care for disadvantaged and vulnerable. They're more likely to care for minorities. And more importantly and more significantly, there's no subconscious way our minds work in making decisions that we think are rational and evidence-based, but in fact, in many cases are driven by our subconscious values and attitudes. And there are studies now that show that medical students, pharmacy students, nursing students, medical residents and practicing physicians, when you look at minorities and students and clinicians of mixed-race, there is no implicit bias in their decision-making and their decision about the delivery of clinical care. When you look at white physicians, white students, white nursing students, white residents, there is a bias against minorities and it has significant impact in the delivery of both ambulatory and hospital-based services. So, talk to today about white physicians' contributions to creating the primary care infrastructure and capacity. I believe it's a major federal mechanism to provide skills in the care of vulnerable and disadvantaged. It's the major mechanism to increase diversity in the health professions with tangible outcomes and it's a major mechanism to create pipeline and faculty retention programs. And it's because of this history, because of this data, I then argued and worked so hard to get it reauthorized. This is a package of programs. It's not one. And it really is designed to develop the pipeline from K through 12 all the way through graduation to the practicing position. This is a program I used to run, the Title VII Training and Primary Care Medicine Dentistry Grant Program, which I'll talk the most about. This is AHECS. These are based, state-based. They develop pipeline programs. They create community-based clerkships for professional students in nursing dentistry and medicine. They develop continuing education programs for health professionals and they tie all of this together in an integrated network. This is Health Careers Opportunities Program. Inside HRSA, federal data shows this program has the highest impactor. The dollars going in to train students to enter the health professions result in more students actually enter them than they enter into the health profession. These are the core and these are rural interdisciplinary training programs. When I was here as a fellow, I started working on this. I had run the federal program Title VII for several years. I came out and was invited to put together a special theme issue of academic medicine. And so much of the next year and a half was actually I think this actually had traction on the hill when the health reform bill was being written. So as I shared with you last year when we talked about the history of this program and wasn't relevant to include in health reform, I laid out four errors. I'm not going to talk about Phase I, which was capacity building. In those 12 years, we built 40 medical schools in increased training positions but as I shared with you before, this period was really the transition in the racial integration of health professions training. So when we increased capacity, we were still largely a white profession on the outcome of that phase. Phase II is what I'm going to start with. It's a landmark legislation in 1976, the Health Professions Training Act. There were three pieces of legislation in this phase in those 15 years. And the portfolio programs that we now think of primary care, which is family medicine residencies, departments of residencies, divisions of general medicine, primary care medicine training programs, general pediatric training programs, PA profession, nurse practitioners, all of these programs were really built in these 15 years. By the end of 1991 we started building out the training in primary care medicine dentistry portfolio with pre-doctoral curriculum in medicine and physician assistants, residency training in medicine and dentistry, and faculty development in medicine. What does Title VII do? There's no other federal program like it. It provides salary support to individuals to create new curriculum, new training partnerships with community organizations to create rule-based training tracks to strengthen and support administrative infrastructure to disseminate findings and outcomes. It provides medical student stipends for summer experiences and fellowship stipends for fellows to get MPHs, Masters of Education and Masters in Clinical Science. So as a consequence, what was the outcome of this first 15-year phase? Well, there were over almost 100 departments of medicine created with federal funding. There were 390 family medicine residencies. There were 12 in 1969 when family medicine was created and by the end of 1991 there were 390. There are 51 new general dental residencies and ambulatory curriculum and training faculty development was widespread through nearly every medical school in this country. I'd like us to appreciate the dollars that went into creating this infrastructure because it has enormous impact on the conversation today. And as you can see, in 2009 dollars, residency training and family medicine for this 15-year period alone was 411 million. Establishment of departments of family medicine, the federal government infused residency training in general medicine and general pediatrics, another 144 million in 2009 dollars and PA training and dental assistant training 268 million. Those are huge dollars. Today, they would have an enormous impact. So let's just look at residency training alone. These are the dollars for family medicine residency training, 750 million over a 10-year period. If you figure that having 75 million just for residency training in family medicine today you would think that we were rolling in cash. And you can see why we ended up with 390 family medicine residencies if we're fusing this much money into the system. Similarly with general medicine and general pediatrics. So much so that by the end of this decade, general medicine has been retained as a specialist within internal medicine. And this is the era of the doubling, tripling of NIH budget every single year. So the drive to specialization is going on at a rapid, rapid pace. And yet Title VII is buffering that. It's allowing the workforce to still retain a diversity and a primary care emphasis. This is really striking when you look at the PA program. In 1973, 39 out of 41 PA programs received Title VII funding. And every Title VII funded grantee had to concentrate on primary care ambulatory based training. It's no surprise that 75% of PAs by in the first 25 years actually went into primary care. Partnering with family physician, a general internist or a general pediatrician. And as the number of programs continued to grow and the dollars remain stable, their impact on PA training diminished year by year. So now the majority of PAs continue to do something in primary care. But the great it's almost now 50-50 with them going into specialty care. Phase III. And this is the era that I know best. The program was changed completely. And the new emphasis is on training skills and care of vulnerable and disadvantaged populations. We have two major pieces of legislation. And as you can see, every grantee, every program, every discipline is now required by the grant guidance to address a major indicator on healthy people 2010, which means all of them have to address some aspect of health disparities. Create clinical and training programs that target these vulnerable populations that are specified in the legislation. These funds were used to develop evidence-based medicine, palliative care, and after the Surgeon General's report came out that said early dental caries and dental disease leads to long-term morbidity and mortality or all health became a grant guidance priority. When I was there, we added cultural competency, health literacy, professionalism, patient safety quality improvement. So you can either look at the glass half full, the glass half empty. The glass half full, the dollars are going down when adjusted by inflation. If you look at glass half up, they're actually increasing in hard numbers. But the bottom line is funding stayed stable in the 1990s and the early years of this decade. So much so that every year there were about 120 awards granted. This cycle, 37 were awarded with half the amount of money available. When I ran the program, Title 7 was the largest grant portfolio in all of HRSA. I had 456 grantees. So much so that this program was having an impact. Even though the dollars were diminished, they were still infusing money to promote primary care. At the same time, we had four to five million dollars available to issue national contracts and cooperative agreements. And I'll talk about a couple of those because this is another place where Title 7 was having an impact on creating an infrastructure around primary care. So what were the outcomes of phase 3? Clearly increased diversity. Clearly increased competence and outreach to vulnerable and underserved populations. Clearly new curricula in health disparities. Faculty development and fellowships with fellows doing research in health disparities and inequities. National contracts, we'll talk about a couple of those. In fact, there were 35 national contracts issued during this period. So here's some data. Title 7 programs graduated four to seven times more minority and disadvantaged students than the national average. Graduates of Title 7 programs were two to four times more likely to practice in medically underserved communities with disadvantaged and vulnerable populations. And that's in every program, the residency training, the PAs, etc., etc. This was another study that was done by the Graham Center in Washington, D.C. looking at the factors that influenced student and resident choices. And they wanted to look at the impact of debt, national service course scholarship, medical school, Title 7 funding to a school, salary differential between specialists and generalists, public medical school versus personal on a student's career choice. And what they did is they matched data from the AMA master file with the funding history versus funding history of that program and then data from the W.A.M.C. graduation questionnaire. And what they found is that this study affirmed the positive relationship between Title 7 exposure and most of our study outcomes despite severe reductions in Title 7 funding. And what were those? Career choice as a family physician is numbered as on the top. Career choice as a primary care physician practice in a rural area, practice in a federal quality health center, practice in a community health center, practice in a rural health center. So I could go down the list, but you can see that Title 7 is having a positive impact on those things that we believe are at the root of improving health disparities. This comes from the 2006 report of the advisory committee on training in primary care medicine dentistry which devoted its report to Title 7 care of disadvantaged and vulnerable. And as you can see the great majority of grantees are doing some work addressing Title 2010 health indices and they are improving access in significant ways. When I ran the program I was asked to contribute to an HHS report on what we're doing to care for the homeless. So I queried the Title 7 grantees and I said, what are you guys doing in terms of curricula and clinical outreach to homeless populations? I got 75 responses back saying we're doing all kinds of things as part of separate electives, some health disparities programs and service learning activities. But what was stunning to me is only four of those grantees were actually getting funded at that moment in time to actually do those programs. What's said to me is that earlier funding had built the infrastructure for this kind of initiative and those grantees continued them after the funding had ceased. Let's talk a little about medical student resident faculty and then we'll close with you here. National contracts, American Medical Student Association the largest medical student organization in the country, received a number of them. These are two of them. One was Prime, six year contract. 10 grants were given to 10 schools specifically to develop curricula in cultural competency and care of vulnerable populations. What really came out of that was a learner's guide and lessons learned on how to implement these curricula and the insight that bringing faculty on board from the beginning was probably the most important thing in terms of achieving success. The ATOM contract, Achieving Diversity and Medicine Dentistry, was probably the first effort at the pre-doctoral level for medicine and dentistry to come together collaboratively, developed pipeline programs and community-based interventions, as well as to implement collaboratively curricula and cultural competency. This was a study that was published in the 2008 Academic Medicine Theme Issue, a study done by Alex Green and Joe Bettencourt, where they did a national survey of residents randomly selected in Falling Medicine, Internal Medicine, Pediatrics and what they found half were in Title VII Residencies and half were not. They surveyed, they had 28 items on their Likert response questionnaire and what they found is that residents who were trained in Title VII funded programs were much more skilled in delivering culturally competent care and here you see the data that they publish in their report and p-value of less than 0.05 in 6 out of the 10 areas. These are two articles on faculty development also published in that same theme issue. Tom DeWitt and Tina Chang talked about the impact of Title VII funding on the development of academic pediatrics and that pediatric fellowship programs were now enabled to give money to their fellows to do MPHs and Masters of Clinical Science and all of them were doing research on vulnerable populations in their catchment area. This is a wonderful study by Ellen Beck and Diane Wingard and they developed a program at USD which was three one week intensive faculty from over a six month period between 1999 and 2003 and in 2003 with their subsequent Title VII grant they expanded this and added a one year fellowship. By 2008 107 participants had from 29 states and Puerto Rico and this is dated from their first cohort of 50 faculty who participated in this intensive program devoted to training them just for vulnerable and disadvantaged populations and as you can see there were 16 underrepresented minorities 29% more spent more than 50% of their time working with underserved 19 of them developed new curriculum for students, 30 for residents 29 had created modified community rotations 29 were PIs or co-PIs of research grants 11 of which had been approved and six were pending so we now enter into era four and the question was was Title VII going to be reauthorized with the health reform legislation and what would it look like this is what it looks like they retained the commitment to the medically underserved community preference which is if 50% of your graduates serve in medically underserved communities you get a special priority for funding there's the primary care priority the diversity priority, collaborative priority as well as an emphasis on vulnerable and disadvantaged populations and the continuation for curricula and cultural competency and patient safety quality improvement there are now five year grants with absolute explicit requirements for outcomes and Marshall said we do a lot of this stuff but is it effective on the downstream patient outcomes and that's what these grantees are now supposed to show there are new priorities for the patient-centered medical home linkages with community health centers and for the first time in 40 years no disciplinary preference but what's also important is that the minority programs were reauthorized with the legislation and John Maupin and Wayne Riley president of Morehouse and wrote a commentary for the theme issue and they talked about the absolute dependence of historically black universities colleges and historically black health profession schools on title 7 funding and they really argued that eliminating these programs would really put this country in jeopardy of having a diverse workforce so the recommendations for funding for the primary primary care training medicine dentistry program the advisor committee in 2003 recommended $198 million, $2,400 $2,006 $215 million the ACA actually reauthorizes the program but our request was $125 million why? we thought we could get this we absolutely thought we could get this and what I'll show you is if we had gotten this this would be huge here's the budget here's the 2011 budget okay so I come in here and I have $88 million to work with that's a fair amount of money to work with Rita, Wilma, Katrina Hurricanes came in and congressional budgets were slashed these are discretionary programs they all got slashed as you can see the number coming out for my program was $28 million before we got finished I had gotten it up to $40.8 million but you can see since 2005 since this period of the hit we really haven't done all that well we're still struggling so if you had given me $125 million instead of my $54 million that would have meant three times the amount of grants I believe that Title VII again would begin to have a footprint on American medical education so I think the jury I'm not certain what Phase IV is going to be whether it's going to be a watered down Phase III because we have insufficient funding or whether we're going to build the dollars back up and actually make a difference and why is this important because residents aren't choosing primary care and they're especially not choosing it because they're not choosing medicine and without these dollars I'm afraid that we will not be able to sustain the primary care workforce that I think is essential to deliver high quality low cost equitable health care in this country so eliminating health disparities remains a national priority and there is no other program I believe that is designed or able to develop the clinical skills of health professionals and health institutions this program has enjoyed strong bipartisan support from its origins in 1976 with Ted Kennedy on the Senate side and Paul Rogers a Republican on the House side but with the November 2010 elections reflecting an American public that wants fiscal restraint will Congress guard America's safety net or have we arrived at the station and are being asked to get off the train and I really will leave you with this question without Title VII driving curriculum and the training of America's future health professionals will health disparities worsen thank you