 Please come on in and take a seat. And let me remind you to please turn off your cell phones. I'm Dr. Ruth Bergren, director of the Center for Medical Humanities and Ethics, where we teach ethics and professionalism while nurturing empathy and humanitarian values. I welcome all of you to this eighth lecture in our Conversations About Ethics series. This series is the result of a partnership between our Center for Medical Humanities and Ethics and the Ecumenical Center for Religion and Health through the generous support of Methodist health care ministries. In this series, we strive to bring diverse perspectives to San Antonio in order to stimulate questions and catalyze meaningful discourse that can inform ethical decision-making at all stages of life. I now ask representatives from our partner organizations, the volunteers and the committee members, please stand and be recognized. They're here somewhere. Representatives from Methodist health care ministries, the Ecumenical Center, and our student volunteers, members of the committee. Thank you very much. I have some important housekeeping details. First, now cast San Antonio is at the back of the auditorium and is providing a live feed of this event online. We're also telecasting to our sites in Laredo and Harlingen. There are several ways to engage in this conversation. For a live audience, you picked up a card and a pen on your way in, I hope. Please write your questions on this card during the panel presentation. And as the panel concludes, pass your cards to the volunteers. We'll have some students that will be positioned in the aisles. All sites may send questions online to MendingGaps at U-T-H-S-C-S-A dot E-D-U. So please keep the conversation going online at nowcasts-a dot org using live chat, Twitter or Facebook. The video will be archived at nowcasts-a dot org. Neither the presenters nor the planning committee members have relevant financial or commercial interest to disclose. To receive medical or nursing continuing education credit, please complete the electronic evaluation and the statement of attendance. Your red card has details and you will also receive an email link after the presentation. For questions, please visit the CEU table to ensure that you receive credit. We do value your feedback, so please thoughtfully evaluate tonight's program by mail, email, or use the QR code on the back of your program to complete the evaluation on your smartphone or your iPad. For any of these details that might be unclear, please see one of our volunteers. They'll be glad to help. So I'm inspired to see the variety of groups that are represented here. We have representation from the faculty of the Health Science Center, students, doctors and nurses, dentists and PAs, promotoras, politicians and patients. And we're here to consider how to give every San Antonian access to a basic minimum package of services that we need to take care of our health. And why should we care? We should care because if my daughter sits next to your son on a school bus and your son is coughing up the TB germ because he didn't have a primary care doctor to treat his tuberculosis, then my daughter becomes infected with tuberculosis. And if your son had a primary care doctor and got the prescriptions but couldn't afford the meds or was surrounded by adults who didn't understand the importance of the treatment, then my daughter is not only at risk for getting tuberculosis, she can get infected with multi-drug resistant tuberculosis for which surgery might be the only cure. You'll have to excuse me, I'm an infectious disease doctor. So of course I started with an infectious disease example, but if that one doesn't work for you, try this. If my uncle gets chest pain and gets diverted away from three San Antonio emergency rooms, each of which is overfull with patients waiting to see a doctor because they have no other way to get healthcare, then my uncle is sentenced to having his heart attack in the back of the ambulance, driving around the city looking for an open emergency room and my uncle may die. What I'm trying to say here is that your healthcare affects my healthcare. If you live in my community and your health is in danger, then my health is in danger. This evening, ladies and gentlemen, we will learn that for many residents of Bear County, access to the basic minimum package of services to maintain the health of all our citizens is across a very tenuous bridge. That bridge is threatened by legislative budget cuts to everything from health services for the mentally ill to cuts for higher education, which feeds the pipeline of tomorrow's care providers for South Texas. None of this is rhetoric, none of this is hypothetical. Tonight, we'll look at real data from our own community of San Antonio and Bear County. We will learn of five major areas of health concerns where the outcomes are drastically different, depending on whether you live in Terrell Hills or the East side, whether you live in Alamo Heights or on the West side, your zip code, your income level and your education have more to do with your health outcomes than you ever could have imagined. We will examine these disparities with the unbiased light of statistics and we will ask leaders from five sectors to comment. We will ask what is being done to address these problems from the standpoint of academia, from the for-profit and the not-for-profit worlds, from the standpoint of our state government and from a community of grassroots health workers unique to this part of the country, the promotoras. We live in a diverse community whose health issues are deeply entwined with education, income, language abilities and cultural backgrounds. Our health affects our productivity and therefore our economy and our collective future. As a member for the steering committee that worked with the mayor to put together a vision for SA in 2020, I ask you to join us in planning for a vibrant city where health and education are the pillars on which we build a more prosperous and equitable society. Tonight we begin a dialogue about how to bring these visions to reality. Let me tell you what tonight is not about. Tonight is not a debate about children's hospitals or disease palaces. It is a civilized discussion meant to shine a light on our biggest health problems to stimulate our most creative solutions. How do we keep San Antonians out of the disease palaces and in the workplace where they can be happy and productive? How do we change our behavior to reduce the risk of diabetes, obesity, teen pregnancies and infectious diseases? Tonight is not about external interference, libertarianism, socialism or communism if any ism is to be invoked, it is humanism. The notion that we are bound together by an interdependent society and that we are meant to care for one another not just because we want to but because we need to. We draw inspiration from the words of Martin Luther King who long ago asserted that of all the forms of inequality injustice in healthcare is the most shocking and inhumane. Let us therefore bring our best and most creative selves to this discussion table. Let us listen carefully to the description of the problems and the proposed solutions, identify the gaps where no sector has effectively stepped into the breach and may the seeds of our creative innovation be a model of inspiration to the rest of our state of Texas and to our country. Now I'd like to welcome to the podium Dr. Brian Alsop. Dr. Alsop is currently the chief medical officer and executive vice president for University Health System. He previously served as the assistant director of health for the city of San Antonio after 12 years of service on active duty in the US Army Medical Corps. Dr. Alsop is a primary care physician with board certification in preventive medicine and public health. He holds faculty appointments at the University of Texas Health Science Center School of Medicine, the School of Public Health and also Trinity University. Please welcome Dr. Alsop. Well thank you Ruth and good evening everyone. We are here to talk about health disparities and I hope from Dr. Bergen's comments that you will understand why we think that this is truly an ethical issue for our community. As in many other large cities there are serious health disparities that exist in San Antonio which you will see with some of the data presented that are clearly evident along racial and ethnic diversity. They also correlate with other factors like income, residential area, and education level. This panel will focus on those disparities. It's our hope that an open discussion with these community leaders and health professionals that we've assembled here will really help bring clarity to the issue and elevate the discussion to affect positive changes in health care policy, environment, and lifestyle. Our goal for this presentation is ultimately to catalyze constructive public conversation about health disparities, particularly as they relate to outcomes here in Bear County. So with that as a prelude I'd like to introduce the members of our distinguished panel of presenters. Please note that there's actually a brief bio of each of them in your program. If I were to actually try to cover all of their achievements we wouldn't have enough time for the panel. So please take a look at that. We actually have them here in the front row partly because they can actually see the presentation. So I'm not gonna ask them necessarily to stand up but I'll give you a brief introduction of who they are and what we're gonna ask them to do here. They'll each come up and give a presentation. They've been given a certain amount of time for that and at the end we'll ask them all to come back up here and sit as a panel. And then we will field some questions from the audience and from those that we're receiving online. So Dr. Anil Mangla who serves as the chief epidemiologist at the San Antonio Metropolitan Health District will introduce our topic. He will talk about and demonstrate data on key disparities in health among specific groups here in Bear County. Responding to all of these data and to discuss both some of the successes and challenges that exist here in our community. Representing many of the disciplines that Dr. Bergen outlined include other members. This also includes Mr. Kevin Moriarty, President and Chief Executive Officer of Methodist Healthcare Ministries of South Texas. Dr. Efrem Castillo, Regional Medical Director for Well-Med Medical Management's Direct Network Group. Dr. Robert Ferrer, Professor and Vice-Chair for Research in the Department of Family and Community Medicine here at the UT Health Science Center at San Antonio. Ms. Martha Castilla, Founding Director of the Edgewood Family Network. And finally but by no means least, Senator Leticia Vandeput who is currently serving in her fifth term as State Senator for District 26 and as many of you know is also a practicing pharmacist. So before we begin, please welcome these panelists and join me in a round of applause. So to start us off, I'd like to invite Dr. Mangla to come up to the podium. Good evening, ladies and gentlemen, Senator, representatives, councilmen and colleagues. It is an honor to present the data for San Antonio on this great occasion where we're going to be looking at different sorts of disparities. Growing up in Africa, in the midst of the apartheid era, this is a very important topic for me. It's actually passionate for me. And as Dr. Bergen brought up a story of her daughter and how it works, how public health works, let me bring a story into consideration. During the apartheid era, I actually was involved in some type of critical illness and due to that, because of ethnicity, in South Africa, we could not attend certain or we were not admitted to certain hospitals. Due to the lack of access to that care that I could have been provided, illnesses get worse. And so this gives you an idea that even in the apartheid era, we had that lack of access. This is what we have here and this is more the ethics part of health equities. So what we're going to talk about today is moving forward to a healthy community. How I have actually broken up and divided my speech is into different categories. And these categories are the key five health indicators that affect the city of San Antonio. These are teenage pregnancy, diabetes, obesity, infant death, infectious disease, and I'll talk a little of the conclusions that we have. Let's look at disparities. When we talk of disparities, as I have mentioned, it's a difference between two or more populations. But what we actually look in at here is the incidence, which is new disease, prevalence, which is the disease that occurs as well as disease that is in the population and then the outcomes of the diseases that is the disability, injury, and death that occurs. Then we have disparities in healthcare. And this disparities in healthcare is also looking at difference in different types of population groups. But here we're looking at more healthcare access, coverage, quality of care, including difference in preventative diagnostics and treatment services. Many of these two disparities involve a few things that Dr. Alsep also brought into consideration. And these are access to healthcare. Some is education, and I'll discuss some of the parts of education. You're looking at income and then socioeconomic conditions. In public health, the key phenomenon that we need to focus on is looking at age distribution. When we look at age distribution, this is our latest data with the 2010 census illustrating the distribution of our population ages. But when we look at public health and you look at programmatic factors, we need to make sure that we tailor public health to accommodate the changes in race and ethnicity. And if we don't do that, we're gonna end up in really problematic decisions that are made at both city level and state level and a national level. And when you look at population distribution that I have right here on this graphic here, distribution is pretty even when you look at ages around starting from age 10 to about 60, then it changes. But let me give you a scenario when you really start massaging this data and you look at the ethnic differences. So 7% of our population year is 70 years and above. The break, if you look at this further, the breakdown of this is 43% of that is Hispanic, 49% white and 6% African-American. Let's look at the ages which are the baby boomers, 45 to 65 years of age. If you look at that breakdown, you're gonna have Hispanics to be 51%, whites to be 38 and African-Americans to be eight. I'm gonna go to a lower age where we're looking at the population which is from zero to 10. The breakdown there is Hispanic 70%, whites 20% and African-Americans 7%. So you can see as the new generation of kids are growing up, that whole ethnicity is changing. And when we look at public health, our programs need to be tailored according to that disproportionate distribution of race and ethnicity. So as we looked at the younger population, let's start looking at teenage pregnancy. The graphs present three different areas. Number one is the, let's look at that. We're looking at the birth rates for the state of Texas, which is green, birth rate for San Antonio, which is red, and then the birth rate in the US, which is your blue. From 1994 to 2010, our birth rate decreased in Bear County by 36%, which is great. We actually also surpassed our San Antonio 2020 goal, 2020 goal, which was actually 54 births for every 1,000 females, age 15 to 19. We have now projected our goal for our 2011 number as rates for teenage birth is 42.1. However, that's our projected number. We have a number that is a preliminary number, which is 45 births for 1,000 females, which is much lower now than when we look at the rate of Texas, but as you can see, even as we get in better with our rate, birth rate here in San Antonio, we still are 1.5 times higher than the national average, which is concerning where we got to do some work. But if you break this down into ethnicity, you can see there's a clear difference and a disproportion between the races. There is actually a 2.3 times higher rate of birth in the African American population compared to the whites. And there's a 3.3 times higher rate in the Hispanic population compared to the white. So this clear shows you that we have some type of disparity. Now let's look at our diabetes rates here. Some of the information we have here is completely new to the public here in San Antonio. We have new databases where we actually started looking at better analysis and getting some real data what we can share and be more transparent with the community over here in San Antonio. When we look at diabetes, diabetes is on the rise nationally, but diabetes is also on the rise in Texas. As you can see from 1995 to 2008, our diabetes rate has increased. In 2008, our so-called BRFSS survey, which is conducted by CDC, showed that 9.7% of Texans were obese, were diabetic. That is higher than the national average, which is 8.3%. But when you look at San Antonio, and you look at Bear County, our number there is 13.6% of our population is diabetic. This is 1.6 times higher than the US prevalence, and it's 1.4 times higher than the Texas average. When we break this down, and you look at this more carefully into race and ethnicity, our 13.6% is our prevalence for diabetes here in Bear County. But as you can see, it affects the Hispanics disproportionately compared to whites, where we have 16.7% of the Hispanics diabetic compared to whites, which is 8.8%. But further analysis of the data also showed that education plays a key role in this disease, where people that have graduate degrees, there were 8.3% of these categories, these individuals that were diabetic compared to the non-Granowitz, which was 15%. We tried to map these with Bear County, and this is how the map actually looks with different zip codes. I just want to make it very clear that due to lack of some data, and we have areas which we could not map that was actually in areas that are white. But you can see areas that there is a large amount of diabetes and the prevalence, where we have 33% to 50%, and those are the zip codes which are indicated in red. Now it doesn't just stop there when you look at diabetes. We look at diabetes, and we look at diabetic-related conditions, and a key one that we looked at is amputations. We look at amputations and we look at Bear County. We rank the highest in taxes when it comes to all our counties, where we have 9.3% for 10,000 individuals that actually have had diabetic amputations. You can see the amount of people that were diagnosed with diabetes is 39,376. Now this was hospital discharge data that was from 2009. What makes this more interesting is if we massage the data even further, we get results where it clearly shows that when we compare the white population and when we compare the Hispanic population, Bear County Hispanics have twice the rate of diabetic amputations as white non-Hispanic population. So this is very clear from the data that we have kind of massaged. Another disturbing fact is we started looking at 2010 data, hospital discharge data. When we look at that, the rate of diabetic amputations has increased another 20% compared to the numbers we show in you right now. So we had diabetic amputations that were 1,122 in 2009, 2010 that number went to 1,847. You can see there's a big difference when it comes to diabetic-related amputations. Now let's look at another key disease that affects our community is obesity. When we look at obesity, the green line shows you normal weight. And then we have, according to the CDC guidelines, overweight. And of course then we have obese. And overweight is a PMI of 25 to 30, obese is a PMI of greater than 30. You can see in the state of Texas, less people are having normal weight. The number of individuals that are becoming obese is increasing. And in Texas, with the BRFSS data, almost 29% of the population is obese. If you look at that, where do we stand in Bay County? In Bay County we are a little higher than that to almost 33%. But when we look at that number and we break that down again into different categories, with the survey that CDC conducted, we looked at income in this category and we looked at race. And you see that income had not much statistical significance when it came to normal weight. But it had a significant difference when it came to looking at as people's salary, as the income increased, you can see that it was very clear that the obesity rate decreased. However, if you look at race again, the African-Americans are more likely to be obese almost two times more than the white counterparts. And also when you look at the Hispanics, they're 1.4 times more likely to be obese than the white counterparts. We also looked at childhood or adolescent obesity. And this is from a survey that we have which is called the YRBS survey. And as you can see, 33% of adolescents that are school age, 12 to 18, overweight and obese. The distribution is 39% are males, 26% females. But again, it disproportionately affects the black population and the Hispanic population by 35 and 37% of the adolescents in Bear County are either overweight obese compared to their counterparts which are the white kids which is just 20%. Let's look at infant mortality rate. The infant mortality rate here in Bear County has been pretty consistent with the number of 6.2 infant deaths per 1,000 life births. This is very similar to the national trend which is about 6.1 deaths per every 1,000 life births. San Antonio has what's called a PPOR analysis, Perinatal Periods of Risk Analysis. And this is conducted by looking at the fetal deaths from birth certificates. And we looked at birth certificates from 2006 to 2010. Now what we're looking in this graph is, as you can see, there's again disparities when we're looking at races. The white line is showing you that is actually an internal reference. And the internal reference is white women, non-Hispanic, at least 20 years of age with a high school or GED. In this graph, we can see clearly that the African Americans are twice as likely to have an infant death compared to the reference group or their white counterparts. And the Hispanics have almost a 1.5 times more likelihood of having a death compared to their counterparts. We're going to go into too much detail here, but if we do a large amount of outreach and education, we can almost save 284 babies when we're looking at this type of analysis. The other key area I want to just discuss in the next 30 seconds is looking at the syphilis rates here in Bear County. And as you can see here, our syphilis rates are almost twice the U.S. and Texas average, which is concerning. We have almost three times more... It's three times higher in the African American and Hispanic population compared to the white population. So that's clearly a disparity there. Because of the increase in these cases, we really see that our congenital cases have increased. And in the past year, our congenital syphilis cases has increased 90% to the same period last year. HIV has started to increase. We're very similar to the Texas average, but what has happened in the past year is our numbers has escalated. Our average actually here in Bear County is a rate of 14.8 individuals per 100,000 population. For the 2011, that has gone up to 21 cases per 100,000 population, which is much, much higher now than the Texas average. Again, if you look at the race and ethnicity, there is a big discrepancy in the data as shown. The other concern we have here is hepatitis C. And CDC has actually given recommendations that all baby boomers be tested. As you can see, almost 2 million, the 3.2 million Americans are affected by this disease of baby boomers. In Texas, if you look at our population, almost 24% of our total population are baby boomers. Liver cancer rates, again, if we look at this, our rates here in Bear County are much, much higher than the state of Texas and the U.S. average, which is 22.1 per 100,000 population. As I had mentioned, education is key and one of the strongest predictors of health. If you look at this analysis that was performed recently, as you look at the percentage of economically disadvantaged children attending schools, as that increases, you can see the SAT scores decrease. Again, when we look at the distribution here, it is very clear that the education attainment bachelor's degrees, the white non-Hispanics has the highest amount of degrees compared to the Hispanics and African Americans. Here we look in a dropout rate where the Hispanic population has, again, a higher dropout rate than the white population. And on that note, I want to acknowledge a few people that actually assist in providing this data, analyzing this data. And on that note, that's all. Thank you. What disturbing data. Unfortunately, it hasn't changed in a lot of years. However, it has the possibility to change and that's what I think I'm going to talk about today. These are some of the many faces of social and economic injustice, often challenging the ethical framework by which we live our lives. And it's from an ethical framework that we make decisions and choices that force consequences, gives shape, and potentially influence the broader network of people, policies and systems around us. While it's difficult to give a comprehensive definition of justice, most of us can recognize clear examples of serious injustice and ethical breach where they arise. And if you look at this data and you see disparities across all these lines, you know there's an ethical breach here, a complete one. Looking back at history, you can see times when human rights have been clearly violated, incidences of ethnic cleansing, war crimes, government sanctions. However, there are also forms of systemic injustice that may persist. These traditions and structures give rise to profound injustice that may be difficult to recognize. These have been sanctioned and escalated by bipartisan issues and legislative actions without dissent generally from the public, and the political and economic and social rights of many groups. And just think of the fact that we have 16 school districts in town who had you pointed it out. It was created by segregation, and it continues to today, and we suffer the consequence today of those actions of the last half century. We can look back in history and see these incidences and we can see the longstanding impact creating generational poverty, segregation in certain ethnic groups, and eliminating voices in the political processes. We have an opportunity. We have the ability to make a bold and clear commitment to change the fate of the uninsured in the state of Texas. We're out of crossroads. We can either perpetuate health disparities and continue to create barriers to access which are clear and indirect violations of civil liberties, or we can apply an ethical framework that facilitates increased and expanded healthcare coverage to those least served throughout our community and across our state. Now, let's consider this a conversation on ethical behavior and not the flavor of the day politics, because if we put it in a political framework, we'll never get anywhere. We need to talk about what's right and what needs to change. And let's all assume some personal responsibility for our actions and whether we're willing to do what is necessary and ethical to extend medical care and funding to those who suffered historical discrimination and health disparities, as have been pointed out in all of the previous slides. What do we need to do? I'm just going to offer one pathway. I could spend an hour on each of the slides, and I've got seven minutes. So I'm going to look at one pathway to reduce and dramatically change the future health outcomes and disparities for San Antonio, Bear County, and the state of Texas as well. Funding. How easy and simple and right. First, let me use a previous example. As Senator Vanderpute can tell you, and I'll tell you, when we decided to put the CHIP program in place in Texas, Children's Health Insurance Program, we were told by the governor at the time that it was going to be put out at 75% of poverty. We argued to bring it out at 125% of poverty. That succeeded. The Texas legislature said yes. Because we did that, we funded hundreds of thousands of children who were uninsured. When you look at all the data on the CHIP program for all of the years, you can see that the health disparities for those children changed dramatically over time because of that funding in a positive way. We have that opportunity for us today. This chart shows where we are today. We have the highest percent of uninsured individuals in the United States of America, 25% of the state of Texas, or 6.2 million people, 1.9 million children in our counties, and this is what it looks like. It's all red. We're number one in the nation. We're the worst. Therefore, we can be the most beneficially impacted by any policy change that allows money to flow into health care for these individuals in our communities. So why is this even a discussion or a debate in Texas? Isn't just the discussion and affirmation of behavior and therefore a continuation of the same disparities we've lived with as an outgrowth of Texas's discriminatory history? Shouldn't we put it into the context of ethical behavior? This is what would happen if Texas were to implement a moderate increase in funding through the Affordable Care Act. This is 1.4 million people covered in the state of Texas. When are we going to get there? If ever. When are we going to change those historical discriminatory practices? This is what it looks like if we were to implement reform for 3 million Texas, which we have funding to do, and this is what Texas would look like if we would fully implement the available dollars coming to Texas that the legislature has to decide whether or not it's going to accept during the next legislative session. And so in front of you, outside of the context of politics, in the context of ethical behavior, do we want to be red or do we want to be green? Real simple. Real easy. It's about money. Economic disparities, education disparities, access to care, availability of care, all denied to individuals because of color. Create that. Funding care creates that. Very simple. Now I've left at your place the report. You can go on the website and read the hundreds of pages. Go about Bear County and any other county you're in, and you can in fact have all the data you want. Texas gets a free ride for two years. 100% federal on this one. After the third year it goes to 10%. Texas has to put up $100 million to get a billion. A billion dollars to get $10 billion. There's $9 billion a year available. If you just want to do it because of the economic impact, it has a multiplier effect of 1.29 on the rest of the economy. It's money. It's your tax dollars. It's capable of coming back to you. We tend to have this as a political debate. We tend to legitimize that debate by having a debate in politics. And I would suggest to you that that's absolutely the wrong thing to do. It should be an ethical debate. What is right? What should occur? What do we need for our community? Imagine for a moment that every one of those people in Texas, those 6.7 million are members of your direct family. What would you do? What ethical dilemma would you have? If there's somebody else's family, is it different? I don't think it is. My point is that these are all of our family members. We need to take care of them. We have the ability to do that. And if you want to change the slides that we saw before, then we have to fund in the state of Texas. We have to bring these resources in. And we have to bring them in because it's the right thing to do. Thank you very much. Hello, thank you everybody. I'm not going to be nearly as fiery as the previous speaker. But I would like to say that the slides, the very first set of slides, I shared with a couple of the folks at WellMed. And the owner of WellMed, we are a for-profit organization, responded with a one-liner which he's famous for. And it said, very discouraging gives me inspiration to continue to change. And I think that's kind of the discussion. And that's the way we have always looked at things and tried to improve. Our vision, our mission is kind of something that we espouse and we repeat constantly. It's really to change the face of healthcare delivery for seniors. And it looks at ways that we can improve and continually and constantly improve to make the world our little microcosm, our 45,000 patients that we serve at WellMed in San Antonio, better and continue to demonstrate that through outcomes and through, as a for-profit business, continue to show that we can do this, we can improve healthcare and still financially remain viable, the providers do very well with us and the patients do extremely well. So approaching it from that perspective, I think is how we at WellMed continue to do this. We help the sick become well and help patients understand and control their health in a lifelong effort at wellness. And once again, to change the face of healthcare delivery for seniors. The WellMed care model is what we employ. It is a model based on the chronic care model. It begins first with primary care physicians. We all believe that primary care physicians are the guideers, the deliverers of care. They recognize the need to partner with an informed and engaged patient caregiver. And the reason that this sentence is important, especially for this discussion, is it utilizes not just what you would consider the standard doctor's office. We utilize social workers. We utilize outside resources. We utilize the patient's family and recognize them as part of the community of healthcare delivery. And that's part of the practice team. We really strive to think outside the box on just... It's not just going to the doctor's office anymore. It's going to the team's office, if you will. As I said, we use the WellMed care model. There's multiple slides here. And since we are limited with time, one of the pieces that I wanted to really point on is healthcare for all and access. So things to help us with access. And I can get into it further during the discussion is we employ a transportation service, which is at no cost to the patient. So any of our patients can get to anything medically related at no cost. In the senior population in San Antonio, the population that we serve is socioeconomically underserved. They're a little bit the poor, if you will. And they can't get to the doctor's office. What's the best way to get care? You've got to get there to be seen. The best way afterwards is you have to have a team around it to make sure that the patients are able to take their medicine, they are taking their medicine, and that they can get their medicines. So recognizing these, which seem like silly points or things that we all would assume, we've put in place processes, programs to help support those pieces, as well as an entire repertoire of other programs. We focus on quality in each of the metrics. CMS, we serve a senior-based population, but it's a Medicare Advantage program. So we try to mimic what CMS, recognizing that the government, that CMS has some insight and helps develop what we will look to in the future as what we define as quality. But it also helps us, for lack of a better word, judge our providers so that we can standardize and we can report to our providers, hey, you're doing better here or not, et cetera. Each of the metrics has a weight, et cetera, et cetera, but some of the ones that we've looked at are blood pressure, diabetic, patient BP control, colon cancer screening, A1C, et cetera. There's about 24 that we look at and we change them every year to make the doctors confused, but it really keeps them on their toes and there's nothing like a provider that's confused but that has a framework to understand where he's going. This is a buzzword now. The care coordination, we've been doing care coordination for many years and really looking at how we can best benefit and do a plan of care for the patient, for the family, for all of those pieces to continue to improve and have the resources around them. We had a study a couple of years ago, I think it was two years ago, that showed that if you came to WellMed, your chance of mortality, same age, Texas, you died half as much. That sounds funny, right? It sounds terrible. You don't die as often, but I think you guys get the point. By putting some pieces around that, we can demonstrate that you can reduce disparities in health care within a framework that allows for all of us to do well. These are some of the results that we've had and these are just really some simple results but I think you guys get the picture. WellMed, 96.7, National Average, 81.7, annual LDO. Disease reduction in less than 100 LDO. WellMed, 71, National 44. Now this is about two-year-old data. Our data now is much better. And A1C under control, WellMed, 63, National Average, 49. I think this year we're up to like 75%. So our A1C is 75% in a senior underserved population. We've shown improved patient care, fewer hospital admissions, fewer readmissions, and we continue to show in the, and I'll say it, the business that we're in, these are the type of things that we look at. So our hospital days per thousand were 903 in 2009. They're now at 807. It's 100 drop. And this is the one that I think is the most important this last one, the readmission rate. We've actually extrapolated this. So on our patients the readmission rate was 41 per thousand. It's currently 22 per thousand. What that means for our population for our population of about 45,000 in San Antonio, we affect about five to 10,000 people's lives. So when you take the family, you take the caregivers, and you know in San Antonio, there's about five people in every hospital room. So all those folks that have to come visit, all those people now they're not being readmitted as much. It's a huge economic and viable alternative for folks that don't have the means. And so we can help them stay at work. We can help them stay in school, those type of things. So that's one of the ways that we look at addressing the disparity in healthcare. Some things that we've seen and some disparities, funding, funding is huge. And as you were saying so eloquently, it's waist heavy on our mind. Another huge one is we don't have doctors. We can't find doctors to save our life. And it's very difficult. Primary care at this point is extremely difficult to recruit to get them to go into primary care. I was talking with the young man earlier this evening, who I hope will go into primary care. But without these two pieces, we will not be able to address the disparities in healthcare in Bear County. Non-profit, profit, it's a discussion we need to continue to have. Thank you. Good evening. What I'm going to use my remaining six minutes and 55 seconds for our tonight's white chair is to tell you how we're trying to connect the dots on health disparities in San Antonio. And give you a taste of what we're doing about it and say how we might do even more. And I'm going to use the term we very broadly because really no sector is doing this alone and academics is no exception. So Kevin Moriarty just explained why health care, injustices in healthcare are very deeply felt because healthcare is what really rescues people at the time of their deepest need. And so there's a lot of attention and a lot of angst around that. But we need to go further. And the most important idea that I want to get across to you is that fixing disparities in healthcare is really important to reduce disparities, but not the key to eliminating disparities in health because healthcare really arrives too late in the process. And we've understood this for a long time. If you read the Yellow Emperor's Classic of Internal Medicine, I don't know if you've read that, Ruth, or not, it was written 4,600 years ago. And in that work you'll find this statement. The superior physician helps before the early budding of the disease. The inferior physician begins to help when the disease is already developed, when the destruction has already set in. So we can ask, why does the destruction set in earlier in some populations than others? And here's the answer. Although illness is ultimately a matter of biology, something goes wrong in your body, we now understand that differences among populations in the burden of disease are largely due to differences in the circumstances of everyday life. We have disparities because all the factors that make you sick, what you eat, how much physical activity you get, how much stress you have, what kind of work you do, what toxins you're exposed to, whether or not you smoke, how much crime and violence occurs in your neighborhood, whether or not you're exposed to discrimination, what you do with your leisure time, what you know about keeping yourself healthy, all those things are strongly shaped by your socioeconomic status, your culture, your neighborhood, and the larger society. Our major causes of death these days are chronic diseases, but the circumstances of daily life are just listed other root causes. A leading obesity expert puts it this way, the obesity epidemic is a normal response by normal people to an abnormal situation. A useful way to frame the root cause problem is to consider what practical opportunities people actually have to live the lives they value. Looking at opportunities is important because willpower doesn't matter very much if there aren't real opportunities to be healthy. I'm going to show you just a few bits of data from some studies that we've been doing. Here my colleagues and I surveyed 300 low-income patients with diabetes or obesity who attend the Robert B. Green Clinic. We asked them about the opportunities for healthy eating and physical activity, and you can see starting at the top that they report good access to fruits and vegetables and a food store. We drop off a bit on the quality of the produce and even more on its affordability, as is also the case for lean proteins. On the physical activity side, many people report poor walkability in their neighborhoods. They lack places to be active out of the heat in our city, and most don't feel safe walking after dark. So we see some large gaps between what's ideal and what's feasible day-to-day. We followed up this last time with a larger survey of 700 people in seven towns in Texas. Here are the results from just one question about affordability. So you see the opportunity gaps according to income. So in one sense, we have health disparities because we have opportunity disparities. Next, I want to say a few words about why the past few years have actually been a time of great hope for me because our community has started acting on the root causes, creating real opportunities for healthy living. Here's one example. In 2010, MetroHealth was awarded a $15 million grant from the CDC to improve the conditions of daily life in our city. The CDC calls that prevention, so the grant was called and the committee is putting prevention to work. I don't have time to list everything that MetroHealth did, MetroHealth and its partners, I should say, because there were many and I'll show you. But if you look around town, you'll see it. We have new solid bars in over 100 schools. We have new fitness equipment in over 360 schools around the city, courtesy of CPPW. We've had major expansion of Greenway hike and bike trails. We have fitness trails now going in at public housing. We have new farmers markets. We have resolutions for pedestrian and bike plans. We have safe routes to school, which helps create the conditions so that kids can walk and bike to school instead of getting their own a car. We have the Ciclovillas, which we just had the other day. So that grant has ended, but partners like the Y have taken up many of the initiatives. And the grant left a leadership legacy for the city of new food policy and active living councils that can promote healthy opportunities for healthy living. It will take time to know the results, but we know from a publication by the CDC that in New York in December they reported this where they've been at this a few years longer. They demonstrated for the first time that a major city can actually reverse the childhood obesity epidemic. So there is hope with activities like this. And here's a key lesson from CPPW. The lesson is the list of partners. And this is an incomplete list. You see that most of the organizations have nothing to do with healthcare. It's these kinds of partnerships that transform the opportunity landscape for us. So what's missing? What are the main challenges? When is sustainable funding to keep the momentum from activities like CPPW going? It would be helpful to keep creating opportunities at that level. Another challenge is to reach the people with the greatest needs. The system hasn't been working for them for so long that many have lost faith in it. Those communities have to be reengaged. And what it's going to take is a mixture of courage and humility. The courage to pursue changes in institutions, policies and systems. The ultimate root causes that will make a difference for the least advantaged among us. And the humility to learn as we go. Working with partners we don't usually work with. And listening carefully to the communities that we're trying to make a difference for. At the Health Science Center or Institute for the Integration of Medicine and Science is working hard in this area. We've made some progress. The path looks something like this. Building trust leads to greater civic participation. And greater civic participation leads to opportunities for the people involved. So I'm going to end with a segue from our friend Martha Castilla who comes next. She and the Edgewood Family Network helped me with a community study I described at the beginning. And I took these pictures during one of my visits with her. Martha was already doing the grassroots work for the families they served. She was showing them how to eat healthy foods, how to create healthy market baskets and how to prepare that food. And Martha's going to tell you more. So thank you. Thank you. Well first of all I'm glad that we've gotten to this point. I want to tell you that I'm a promotora. And the work that the promotoras have been doing in the community is very important. And I'm sorry but I'm quite, I didn't expect to see the pictures from the effects. I'm here to speak for myself and for all the promotoras and all the families that the promotoras represent. The promotoras that were in the Edgewood Family Network worked with 30 families each. And when I explained this to you you're going to see that wow, with 30 families this is what the work looks like. I want to look at this first because in health disparity indicators if you see school dropout, depression, diabetes, all these indicators, we have the data. And I want to tell you guys that present all this data, thank you. I'm not going to do that. I live the stories that make that data. And why is it important to know this story? So we see the cases and when we want to change and we want to help as promotoras we know we have to develop trust. Nobody's going to open up and tell you what really is happening with your family or in their lives. You have to develop trust. And so how do you do that? It has to be authentic. You cannot buy that. You cannot care for someone based on money. A true promotora will be a promotora till she dies. Whether the grad ends or whether there's funding or not, that doesn't matter to us. We hope you guys take care of that because we're going to continue working because once we make a commitment with somebody we cannot walk away. If we're working in our community we're going to continue seeing the people that we work with at the grocery stores, there are neighbors, there are families. So it's important that we recognize the importance of that work. And we cannot come in with a preset agenda. We have to come in with an open heart and open mind and open ears because we have to listen for a while before we get to tell them anything. Because when you do that then you really understand the root causes of what's happening. And then we can help change the stories. We can help and change and address the root causes that are affecting. So that's why I say the promotores practice it's work from the heart and we value trust before we value the money. Yes, we're going to need the money but hold on, we'll tell you where we need it. Where is the gap? Where is not working? All this data is wonderful but I can tell you a lot of times they say we didn't have money to buy the medicine. And we have to go through things then. Yeah, we have to not only think outside the box but work outside the box and it can be done. One of the things that frustrates us is that there's funding here. Okay, the fund is gone. Okay, let's move over here. So we have to follow whatever you guys are doing or whoever is doing it. We just know that we have to be aware of who's doing what so that we can connect to that. Sometimes it could be very confusing and it's exhausting to keep up with that. So one of the first things also is not judge anybody. Don't judge them because they're not going to open up if we start telling them well you should eat like this and do it like that. One of the first things that we did in Edgewood Family Network was talk about nutrition. But their interest was good. I want to eat like that. But tell me how to fix the food or tell me how to fix what I already buy that way that you're saying. Okay, you're not interested in green beans but do you like nopales? Yes, okay. Let's prepare nopales. Let's look at green vegetables. So that's the kind of conversation that we need to have. And I know that a lot of you start all of us want to help and want to serve but sometimes we forget. The stories can guide the resources to be distributed effectively and not be wasteful because when you allocate things like that then there's scarcity. And once something scares, guess what? There's competition. Competition, competition, competition. And we have to go beyond competition. We have to work together. We do. And one of the things is that we need to be included. We're here. It's not like you're thinking I'm going to go work with that committee. Hello, there's primitores all over the place and we know the stories and we know the people who have created that data. We're part of that. We are here and we want to work with that. We are the voters. So a lot of times when we work as a family how could they not come over there or why could they not see me? The first thing they ask me is what insurance do you have or can you pay this? Well no, I don't have insurance so don't do the pathology report. Don't send it up. They don't use that language and so who's playing God? Who's decides? Who gets coverage and who doesn't? Who gets care and who doesn't? So then we criticize because they want to go across the board and go buy it over there because they can afford it. Or there's a grocery store that has the antibiotic that they need. How do we criticize that? How do we stay and create, stay together to create that healthy community? I don't even know if I should show you. Once we do trust before money then there is participation. There is participation. There's a lot of people. I've trained over 500 promotores in San Antonio. In the Edgewood family networks there were 35 people working there at one point and 15 of those were teenagers working with the teenagers in the high schools. So it can be done. If anything Edgewood family network proved that it could be done. And then we have to be efficient with our resources. Let's not go here and there. And not really know where the money ended or was this a good program or how much did we do. Let's talk about it. Let's look at the stories, the good ones and then let's celebrate the bad ones and celebrate the good ones because they are a good story. So this is how we start. We communicate with our heart that nosotros is a model that is communication, a trusting unit and health is as flourishing. We don't concentrate on the disease. We concentrate on what else in that life of that individual is good. What can make them flourish? How can they become the best people that they can become and we're not going to tell them what that is. We're just going to listen and help and guide. So if we just don't think of the people like this in the heart then we're looking at this when we're swimming out. These are the players. The institutions, the schools, the businesses and it all starts in the home. So when we look at that there needs to be trust throughout in all of them. No competition. The families need to trust the teachers the schools then we need to be effective in whatever we studied or whatever we learned. We provide businesses for that and the institutions are supposed to bring stability in the communities and to the families. Are we failing there? Who's failing? The family will say, hey, hey, hey, hey, you know what, it's not they, it's we. It's not them, it's not us, it's we. We have to concentrate on creating healthy communities to work it in silos leverage each other's resources. These are the language that I learned from you so let's do it now. For you. And take a transdisciplinary approach. Let's think, let's dream big let's think that it can be done. It doesn't exist right now. Let's get our heads together and create it. Still think inside the box and just in the area that we're working we're going to continue like this. I don't want to spend another 11 years and still be up here trying to say, you know what I met somebody that's been doing it for 44 and how many years how many more years. I don't want my grandkids or great grandkids to see the difference. I want my kids to see it. So let's not let's not change the problem for my family because that's why we all started my family has a lot of problems and I want to help somebody else. I already lived through this experience. I want to share with somebody else. I don't want them to struggle with what I did. So we decided a long time ago we should not solve my problems. Let's solve that problem so that it can help everybody. Thank you very much for having me. Thank you. Good evening. I'm let these have and appeared a pharmacist for 32 years and serve now almost 22 years in the state legislature and I have no idea how to follow a brilliant epidemiologist a committed and wonderfully inspirational not-for-profit leader like having a great medical director that's taking evidence-based practices into the community and really getting positive incomes particularly for our elderly and someone who takes the academic teaching world and brings that clinical experience to our neighborhoods and then Rachel where you actually do the work in the community that make your community a better place to live. I don't know how to follow that and so I'm just going to talk to you about a couple of things that might make a difference in an ethical framework for a better health community for San Antonio for Bear County for the place that we love and the people that we love. So I'm going to tell you about my day. I had an opportunity because we have such great educational institutions to go to the University Speaker Series and each of our university has and this one I was going to the Trinity University Speaker Series and on this particular morning it was John Leacham the publisher of Newsweek and I was very excited about going because I had read the year before his brilliant portrayal of Andrew Jackson in the American Line which he won the Pulitzer for so I took my book in a little position in the legislature. I get to sit at the table with the president of Trinity University and John Leacham and he meets me and he says oh you're a legislature all that state board of education I said I know he says what they're doing are dangerous I said yes sir I know will you sign my book and the discussion that he gave was a look at how we transmit in a digital format now what's that going to mean to print in magazines it was a great discussion so I go on my day and I start off 7 a.m. I am sitting next to a Pulitzer Prize winning guy he's editor of Newsweek and then I do many things but then around noon I go and I do my shift at Davila Pharmacy at 1423 Wale Lupus Street in the neighborhood that I love where my family grew up I still live off Sarsamora Street the joke in our family with our six kids is if mom is more than two minutes away from a Panaviria a Molina, a Frutiria and a tire shop she's in the wrong neighborhood they tease us we have my sisters who live in the great area around Civil Oak Canyon's wonderful schools and I can't live there because everything is just beige you need to tell me that I'm going to the lime green you know meat market and the purple Panaviria I need to have that vibrancy and I'm really close with downtown people with Westside people so this is where I've been comfortable and where I lived my dream as a pharmacy owner around Culebra right there in the Loma Park area in Edgewood during the 80s I'm feeling good right I have had the opportunity to sit next to John Meacham and then I go to Davila and I get to be with my patients the box from TBI the zip code that we're working on is the highest diabetes incidence pretty much in the state and nation it's also the 7-8-2-7 zip code which has the highest teen pregnancy, highest drop out rate highest referral or juvenile probation highest rentership lowest home ownership you get the idea and the best place in the world to work and so I'm just about to close up it's about 8-8-30 I'm trying to get the narcotic counts get everything ready and one of the gang bangers comes running through the pharmacy screaming that his friend is dying well what do you do right? you're a white coat what do you do? luckily my staff gave me a pair of gloves because as a pharmacist I normally don't wear the latex gloves unless we're doing immunizations and I run out and sure enough right by the dumpster probably around 19-20 years old there's a young man who is OD'd on a heroin overdose and I try to get the information but for those clinicians who have seen someone it's not a pretty sight when someone has OD'd so after getting the vomit out of his mouth and doing CPR because I realize this is somebody's kid EMS gets there police gets there and all of his friends scatter except one this is someone's child this is someone's brother this is someone's brother this is a person who lives in my neighborhood and he's right outside the dumpster of the place that I work he survived and I go home thinking I live in this wonderful community of San Antonio that is a dichotomy I start the day with business leaders and the Pulitzer Prize winner and I end my day giving CPR to a heroin addict on San Antonio's west side what does that have to do with ethical decisions and disparities it has everything to do with it in this debate nationally and locally about health care and health care delivery a lot has been said about the opportunities we have in the state of Texas and the decisions that your legislature will make that our community can make to increase the number of people who have access to health care and so I hope that you understand that my framework comes from an idea that I believe that this thing called the affordable health care network is nothing more than a belief that every American family ought to have a family doctor and if you don't believe that you're not going to like affordable health care I have colleagues who do not believe that health care is a right that that is not government or community's responsibility and they will vote that way this next legislative session but when we have this luscious proposition of ensuring 6 million more Texans at relatively low cost using all of our hard working IRS tax dollars that we've already put in to me it seems a pretty simple decision but it's not, it's complex I wonder about that young man why did he feel, why was he in the throes of that addiction and why weren't we able to prevent that is it my responsibility is it the communities we do work in silos we can't mix state and federal funds we can't do that, look at what happened here for Haven for Hope when we ripped apart disciplines and for profit and not for profit and community groups and everybody working together what did that mean for that population that was living under bridges and what does that mean it's transformational so maybe what I propose is a community where we are out of the box recent book, if you haven't read it called Disruptive Innovation maybe it's the technology it's the data it's the everything we can use to make our community healthier is it as simple as putting a public health officer on our city planning commission so that when neighborhoods and plots are made that they realize you gotta have walkable communities I would do that I would mandate that of course they would accuse me of being the nanny would I make sure that our teens and our children go to schools where they are not fearful because a child that's fearful cannot learn would I try to make sure that youth that get involved in juvenile justice that we go to the core problem so that the cycle doesn't repeat itself all I did and I was called oh she's that huggathog girl well we're getting results changing that framework much has been said lately if you're an NFL fan or a sports fan about refs and people who are supposed to have the skillset to make decisions not having that and so they don't make the right call what we have before us in healthcare is an ethical question as a community and it's public, it's government state, local, federal it's for profit it's not for profit it's at the community the question for us is are we going to make the right call I look forward to your questions well thank you senator benipute I'd like to invite all the rest of the panelists to come up to the stage we're going to go into a question and answer session now we've received several so far if you haven't or if you have questions please use the index cards if they're for a specific panelist go ahead and note that at the bottom otherwise we'll figure out who we're going to toss the question to I'd like to thank each of the panelists and I want to say to Martha Castilla our representative of the promotora I have to say that I found your tears so appropriate really if you break down we heard that Hispanic diabetics sometimes is likely to have their legs chopped off as white diabetics in San Antonio but black babies are twice as likely to die as white babies these are things that should be causing us to shed tears and so I thank you for sharing that part of yourself and the dedication of your daily work with us my first question we'll go to actually Dr. Nangla and possibly a striking statistic regarding adolescent obesity in which it appeared that the males are disproportionately affected 39% of our boys and 26% of our girls why is there, this is a sort of a disparity in and of itself and I wondered if you could comment on the reproducibility of that discrepancy and maybe speculate as to why we're seeing this Dr. Nangla, Dr. for where Dr. Nangla the analysis we have done is very clear that it shows that there is a discrepancy we actually looked at national data which is very similar to the data we are actually seeing here locally in San Antonio so Nationwide we're seeing greater problem with the adolescent obesity in boys than in girls right so it's a national trend that we're seeing and and Dr. for where is a family medicine doctor doing a comment or speculate about that observation this is more on the speculation side I think but it may be that for girls they're still tethered to an ideal for body image to which boys are not so closely tethered so there's a downward pressure there you wouldn't do video games would it it could be although you know I know a lot of teenage girls that also play video games not to the extent of their brothers perhaps can you do it? to make sure my mic's on we have at least one statistician in the audience Dr. Nangla I think this one's for you is the diabetes program's age adjusted to comparison in San Antonio and the US and also based on weight and ethnicity education comparison so did you standardize the data when you showed them? Yes the BRFS data is weighted data number one and we have standardized it now a lot of the information that we did not use for many of the zip codes because it's the data we had for zip codes was too small so we could not plot anything and so we looked at data's where there was a large amount of respondents in the BRFSS study and so that was age adjusted and standardized accordingly for their fair comparisons okay you know there's one piece of good news out there on the obesity epidemic which Senator will be real happy about because I won't be filing bills in the legislature to make strawberry and chocolate milk a non-dairy product and it's just outlawed strawberry and chocolate flavored milks from all school lunch programs in the nation I've been trying for about six years to get the state legislature to do that the state legislature failed to do that the federal government did that and Dr. Hill did the research here that showed that children who would take in two to three flavored milks per day would have an inappropriate 10 pound weight gain per year and that's why we have obesity and then of course childhood diabetes and all the way down the line so that's good news and maybe we'll see an impact of that in three or four years so I'm going to follow that and perhaps ask Kevin Moriarty and maybe Efrem Castillo to comment on what are the opportunities and benefits from multi-sector collaboration in health and can you cite some examples and I would imagine the one you just cited might have required collaboration across the years. Sure, I mean everything has to happen within the context of the rest of the community and so it's absolutely essential that the whole community work together and being having spent my whole life in health care I'd probably reverse the pyramid of funding and put more money in preventive health care and do the community health education end of the equation unfortunately I'd probably get fired I mean really there's not a health professional out there that doesn't quite understand that spending all of these dollars at the end of life really doesn't make a whole lot of sense from the perspective of changing the outcomes for the future in our country but changing the outcomes for children and teenagers and making sure that their lives are changed we'll change the outcomes from a mobility and a longevity perspective down the line so yeah we don't have to work together but you know we have to put the reality that we know out on the table I mean nobody in their right mind think that it's great to spend half a million dollars on a 90 year old you know I'm sorry and then watch that person die in six months right come on I would agree that we need to move towards a collaborative effort between all the parties involved I think we have to develop the framework agree on the framework and what that framework is the way that we deliver health care in the United States as you said is it's terrible it's embarrassing when you look at the resources that we have and the ability that we currently have to change the way we do things we need to come together all of us and say how are we going to make this work and is it going to be health care this is something we say all the time health care is delivered locally policy is delivered at a much higher level but the way we enact the policy the way we work in the communities the way we do all the things all the great work that everybody's done is local it's at the clinic level we have to work within that framework understand that and move towards that Senator vanipia I think this is for you it's sort of a two part question since health care is so polarized does the political system have the will make changes at the city level since data that has been presented have been known by political staff for decades is there a will and we've known this for a long time and why hasn't it changed I believe that there is a will locally to enact things that affect people's health we've had great victories for example in anti-smoking public laws at the state level that was a long time coming that's probably one of the most effective things that we could do to affect patient health, family health well being obesity is one of the ones but the system of health care finance is complex and I've had some of my colleagues be very reluctant to support for example this opportunity of the expansion of Medicaid to children in higher poverty levels and kind of a wrap around for their working parents because it's going to cost too much we don't have enough primary providers and they'll take up all the space what do you mean they'll take up all the space they'll clog if they've got stuff then they're going to get access and I don't think they realize what a kind of discriminatory statement is being made the political will may not be there but the financial pocketbook we cannot afford with our national deficit to continue to finance health care services in the manner that we have done them in the past and so I think it's really got to be mainly a state-federal partnership what we've heard though it's very unusual on the political side you've heard the governor say no way, no how we're not going to do the health care exchanges we're not going to do the expansion of Medicaid and then a week later I'm going to visit with legislative leaders and come up with a way that's best for Texas I think we'll leave those decisions to the legislature to last week saying health care providers and I think that there is some common ground that we can reach to serve Texans so the political sound bite sometimes is very different from what really happens in the Texas Department of Insurance and Medicaid folks I think those plans have already been there of where do we go on the next step so as the political will the thing that I'm probably the most fearful of your state policy makers in the House over half of the members but over half of them will have less than two sessions experience Senator and that's very difficult I do want to follow up and draw down a little bit on something that you mentioned you talked about the expansion of Medicaid and one of our health care leaders in the audience has addressed a question to you regarding the Affordable Care Act whose decision is it to expand Medicaid is it the governor or the legislature or is it both technically it's both the legislature sets the budget so because for beyond the two years it's a one to nine match for every dollar we put in the federal government will match nine dollars that's probably the most luscious match mate rate that we've ever had except for the women's health program and you know what happened to that but it is something that I think is very compelling I would put in greatly six billion dollars of state resources to draw down over over a hundred billion dollars of health care services that would mean to six million uninsured Texans in a heartbeat but I think we've got to make that that compelling argument and it's got to come from the folks who live in the communities that this is the right thing to do not from maybe because I'm going to tell you I never win an argument on the social justice or it's the ethical right thing to do I have to win the arguments when you're talking about budget and transparency on the return on investment so our business community must make their outcry that this is sound business for Texas that this is great for working Texans it's great for small business owners it's good for our large but that's what it's going to have to take I can't win arguments at the state legislature based on I wish I could on the right thing to do I'll throw this out to the whole panel because I think it's a good one what are the challenges facing the various sectors from working well together I think Dr. Farrer pointed out at least in the context of CPPW there was a venue for a lot of folks who traditionally didn't know each other but how are these other sectors who are represented here or the barriers to keeping them from working together more often and once again you threw it out to everybody but you didn't I don't think they're real you're any barriers let's take this whole issue of the Medicaid expansion in the state of Texas first of all it's not going to be done I agree with you senator because it's the compassionate right thing to do it's going to be done because an emergency room visit is going to cost from $600 to $1000 and that's bad debt a primary care visit is going to be $150 to $200 a unit that makes a lot of sense and so the bankruptcy of the organizations that are trying to cover this at the worst possible level of care an emergency room is going to drive part of that equation and the other piece of this is that when I went to graduate school in 1975 we had a course on how when health care expenditures hit 10% of GDP the United States was going to go bankrupt and therefore we needed to change the health care system today it's 18% of GDP and so the reason you've got health care reform in front of you is because business is unsustainable with a GDP cost of 18% for health care and so the goods and services produced by the United States will no longer be able to be bought anywhere else because they're too expensive and so the business community is really driving the desire if the bank capital CEO Romney the governor of Massachusetts becomes president that CEO who ran corporations is going to do the same thing he did in Massachusetts he's going to say okay back to health care reform I mean the argument politicizing this is specious the politics of this is specious it's about the economic sustainability of this country and that's the problem and most people don't quite get it 18% of GDP for health care unsustainable only country in the world that has that expense with these types of terrible outcomes for our community so it's got to change I have a question that drills down on trying to link governance and economics to actual health outcomes so this person would like to know will increasing the percentage of Texans with insurance lower rates of diabetes and obesity if so how and I'll start with Dr. for where well the answer to the health care part is probably not in fact just this week I saw some data from the UK and I think the title of the article was for diabetes will not lower rates of diabetes and the reason is which I alluded to in my talk was by the time you're screening it's too late we need to move upstream in that causal pathway not have 100 pound 6 year olds anymore to really make sure that kids are at a healthy weight and just lower their diabetes risk vastly when they're 6 and 12 and 18 and then give them the opportunities and the tools to maintain that way through their adult lives but health care in that case it's a rescue phenomenon it's not a prevention phenomenon and the answer lies elsewhere thank you I think this is really more productive are there any data on the projected impact of cuts to family planning funding and the women's health program in terms of teen and unplanned pregnancy rates and access to services so the implication is that that would happen and I think Senators spoke to some of that but are there good data that would show what that impact would be we're working with the school of medicine in Utesca on what type of data we can actually accumulate and look at regarding family planning we know what the family planning cuts there has been certain type of clinics that have shut down when we look at services services have continued now we do have programs that are making sure that people are females have been tested for pregnancy and project worth is doing an incredible job in making sure that school children are educated and again the key is going to be education to ensure that the females teenagers do not get pregnant but even more important is if they did have one child making sure that there is not repeat in pregnancies thank you I have a question for our promotora Martha Castilla someone would like to know have the promotoras or promotores been accepted in families of different cultural backgrounds yes it's easier if they live in the same area of the same culture but yes they have been accepted it takes a while to develop a relationship but if you do walk like I indicated earlier you are there without an agenda and once they understand that your primary interest is their well-being they open up this one is for Dr. Castilla how does wellness financing structure enable primary care providers to afford comprehensive care coordination so what med uses a managed model so Medicare Advantage model so it takes premium dollars from CMS basically it manages the entire care and one of the things that I wanted to comment on so it's not just managing the dollars to provide the better outcome you can take the same dollars and if you don't manage them appropriately within a framework of health care delivery then you can end up with not so great outcomes so I think what we've done is take the dollars put them into a business model because health care as we've all said is a business now put that into a business model that delivers efficient care it's appropriate it comes in quality patient experience etc so that is how we've been able to address it and to your point about preventative there was a study in New England Journal I think a week or two ago about actually treating folks before they got diabetes and how successful they were and what the decrease was and I think that's what we need to do we need to put the dollars into a framework of prevention to promote care and to actually reimburse the primary care providers as well as all the providers in a way that's sustainable as a follow up to that I just wanted to highlight two pieces of data from a publication that WellMed has put out that the part of the mix that leads to these improved outcomes for elderly and Medicare patients is that you have a voucher program providing no cost prescription medications to disease management patients that prevents them from following into the Medicare donut hole and in addition to that transportation is actually available and these are two of the most significant obstacles we see for example when we're taking care of folks in our student run free clinics that are taking care of the refugee population paying for meds, getting the transportation, how does WellMed turn a profit and address those barriers at the same time it's a great question so real simple if someone has heart failure and they can't afford to take their lasics and they can't get to the PCP what happens to them they end up in the hospital and that cost $15,000 we realize that if we do a fund a program it's called the medication assistance program and we pay for their lasics and we pay for them to get to the doctor which cost $25 in a cab right if you will we can do that all day long and we've saved the hospitalization we've saved the patients poor outcome and we've made the community a better place and so that's the way we fund it and that's the way it works and we've been very successful we have it in all the markets that we're currently in in Texas and in Florida the medication assistance program is a little bit more complex and so we're now expanding it from San Antonio into Austin just a quick follow up does one might take uninsured patients we do have a few unfunded the problem that we have is what I was referring to as one of the barriers is we don't have enough providers all our providers are full if you will and so we can't we can't take the all the people that need to get in for like a better way to put it so we've expanded to a contracted network and so we've been trying to figure out a way to expand the services to other to other payers if you will and being unfunded as one of them but we've continued to support community programs to help access senior centers that aren't necessarily our patients to support exercise in these type of programs so I have a question here that was nicely written by somebody in a bright red sharpie and it might be a good one for us to wind up on because I see that Jerry Abraham is giving us some signals about time and this question is I want all the panelists to be thinking about this question and maybe if you can give us a succinct answer we can ask each of you to give to give an answer if you had to pick one social determinant John in Bear County what would it be and do you have an idea to address this issue shall we start with Dr. Mangla the key social determinant that I think is important here the behavior change can everybody here behavior change that's your key determinant right in this because that gets all of them well behavior is important in this view there was just an article that was published last week and it was to do with the question of obesity so prevention is key but when you look at behavior number one is diet is not just going to change obesity nor is exercise but putting diet and exercise together has a major impact and thus again looking at educating folks is going to be the key solution here in helping Bear County well I'll be real easy about this one when I arrived in San Antonio in 1977 right out of graduate school I was 27 years old I came from New York City and I was I was asked to come here to do health and human services planning and I did that for the city of San Antonio and then on the side I did an analysis of the 16 education school districts the resources, the teacher student ratios the counselor student ratios the extra curricular stuff and came to the conclusion as did I have a fair treatment and allocation of resources had the outcome you would expect in terms of poor outcomes for kids so I would blow up the education system in San Antonio there's no reason to have 16 school districts other than a continuation of segregation that occurred some centuries ago that we created this structure to be separate but disequal and we need to figure out how to divide the city up into four or five districts put the resources there to achieve the same outcomes that the highest performing district does for every child in the city and then we have better health outcomes so your one word answer was I'd break up the school districts ditto education thank you for your succinct answer I'm going to put a slight wrinkle on that and Dr. Berger, you hear me say this every year in your social determinants class but educate the girls because it's women often that are making position for their kids' education and all the healthy things that people do in the family and they're the drivers and the Edgewood Family Network I think was all promotoras with an A so thank you I also agree with that and I agree with women because if you educate the woman you educate the whole family and we're always looking towards the future we look at today and see how it could be better for tomorrow so it's education and women and bringing down the uncertainty that's in families that causes all these other health issues Senator Vanderpute taking into consideration what my fellow panelist said I would probably say poverty because even in the best of systems with a great educational system if your family is so poor it does not allow for that hope and I have found that moms and dads and particularly kids if they have no hope they are incapable of making good decisions even if they've got the information readily available it's almost as if they're paralyzed and so for me yes it's the cycle of that poverty and education because how do you get out of it how do you get out of poverty but our poorest neighborhoods are the ones that have the most horrible health outcomes even when they have access to health care personal responsibility or personal behavior risk behavior addiction mental health it's that vicious cycle of child abuse and all of those things that really make our communities unsafe places so for me the one determinant would be poverty and education to me is the strategy to get those families out of poverty behavior change education educate the girls and poverty great way to sum it up I think they just did your work for you but we'll let you come up here the podium to finish up anyway before I begin submit what I think maybe some concluding remarks please join me at least in another round of applause for our panelists I think you've done a great job I've been given the not so easy job some of what we've heard today and maybe comment on the way forward I think all of our speakers an outstanding job from Dr. Mangler we certainly saw some very compelling data some great graphs outlined the five issues that he spoke about Mr. Moriarty really spoke about the historical consequences of social injustice and this ethical framework that we need the importance of funding and then maybe what might happen if we did pursue the expansion of Medicaid I think Dr. Castillo really enlightened us to how well-made really seeks to change the phase of health care for seniors their well-made care model I thought about access focus on quality and care coordination Dr. Ferrer he pointed out that health care is often too late when you're trying to make these changes and I think a lot of our panelists have spoken to that he really showed how some of these socioeconomic variables really lead to disparities even in one's ability to engage in either healthy behaviors or eating he talked a lot about and didn't give himself credit for a lot of the work that was done with the community's putting prevention to work grant the complete streets policies that are still in existence the safe routes to schools the power of partnership I think all of us were touched by Ms. Castillo and not just by her passion and her words but what came through for her is a very personal issue and the value of Promotores and I guess for me and for all of us the value of trust and how important that is when you're engaging families in their own health care it all starts in the home and I think that's true and then Senator Vanity brought us through a very interesting example of one of her days this dichotomy of sitting next to a presidential president and speaker and then working in a neighborhood where she's comfortable and has been a pharmacist for many years but then being faced with an unexpected occurrence of a young teen that ODs know what a dichotomy that is so I think clearly we've got challenges but there also been some laudable successes that we should celebrate perhaps some in recent years but gaps remain and gaps remain and barriers still exist which really impede our progress to improving health access, health literacy and really outcomes particularly amongst those who are most vulnerable and it always seems to be that way so what must we do we must continue to identify areas where we need innovation and collaboration we spoke to that earlier we must engage others in this process we've got a great panel here but there are many who aren't represented schools, space-based groups community centers, businesses business community has an obligation to become part of a wider effort and really expand on some of the successes we have through CPPW, the Mayor's Fitness Council the 2020 we need more people like you we need more people in this audience and more people like you to help us raise the awareness of the social determinants of health and how they directly contribute to this persistence of health disparities that rarely exist this is really our call to action we have to acknowledge that even as healthcare outcomes have improved dramatically over the last century in many ways in so many ways and they endure and these inequalities have probably always existed some degree no matter how we've looked at data or measured populations you can consider the Europeans when they first arrived in the Americas they've even documented the disparities that existed between the health of their own populations and those that they found in the Native Americans that were here and then the African Americans who came over as part of the slave trade we saw with the rise of industrialization the physicians became more familiar with the impact of wealth and poverty on health and that was documented in the Marmot studies so health inequalities remain not merely among races and ethnic groups but also as we've seen among differences in sex in geography, educational level, occupation and many other what I would consider gradients of several variables so although we know there's something about these relationships I think physicians particularly an epidemiologist need better models we really need better ways to incorporate the association between the social factors and morbidity and mortality we don't have a good framework for that we don't have a good formula I can tell you we don't do that well in the health care systems that exist in the United States we're not paid for it there's not a lot of incentives for it so I would challenge this to consider also a few provocative thoughts you know why some health disparities are really seen as maybe the proof in the natural order while others are considered clear evidence of injustice so most of us would probably agree at least in this room that the four year life expectancy gap that exists between African Americans and Caucasians in the United States is clearly unacceptable but what about the near five year life expectancy gap that exists between men and women in this country even across races should we accept that? but it makes you think and so either way for me the recognition that health inequalities exist really should make them a target for intervention and unfortunately historically the opposite has more often been the case the poor or the impoverished marginalized groups have frequently been used against them either as evidence of their inferiority or perhaps even as an argument that they are unworthy of assistance but we should not accept that in our own country's past these attitudes we know have produced policies that have been disastrous in terms of health outcomes for African American populations and Native Americans and sadly they still may lie behind policies that persist today that would limit healthcare access for say the mentally ill or immigrant populations so the stakes of this debate are really high with implications for the allocations of billions of dollars in contested resources health is truly a complex expression of the human existence and we must continue to adapt health policy and health systems if we are to somehow dramatically reduce these pervasive disparities that exist in our society so please join us in the next stage of this discussion at the reception in our lobby and thank you all very much for coming I just want to add one more note of thanks to those panelists Senator Vanderpeet Dr. Castilla Dr. Robert Favere Dr. Efrem Castilla Kevin Moriarty from Methodist Health Care Ministries and Dr. Emile Mangloff from San Antonio Metropolitan Health tomorrow at noon we will hear from a Pulitzer Prize winning author and journalist named Lori Garrett who examined many of these same health disparities but on a global scale and she will be representing our center's programs in global health and tomorrow evening at 6 p.m. we will hear from my predecessor Dr. Abraham Varghese who will speak about the pen and the stethoscope you're all invited everything is free and there's receptions with food afterwards so we hope to see you there and thank you for your attendance tonight