The health of American boys and men – particularly those of color – remains a significant, long-standing public health challenge. Few social problems in our society affect so many people yet are so often overlooked. Disparities in health and wellness among American Indian and Alaska Native (AI/AN) men compared to women and other U.S. racial and ethnic groups on some measures are extreme and the evidence suggests the gap is worsening.

Based on this awareness, a growing group of interested stakeholders from all levels of American society coordinated by the Men's Health Network is embracing the notion that solving health disparities among males demands a concerted effort. Doing so now is even more urgent in light of the health reform spawned by the Affordable Care Act and a recent study of minority men's health .

Several specific causes of death contribute to the higher mortality rates of AI/AN males compared to AI/AN females. The following are noteworthy among the AI/AN population for some age groups:

• AI/AN males experience death rates two to five times greater than AI/AN females for suicide, HIV/AIDS, homicide, unintentional injuries, diabetes, firearm injury and alcohol-related deaths;
• AI/AN males experience death rates 10 to 50 percent higher than AI/AN females for cancer, heart disease, and liver disease.

The reasons for the health, well-being and life expectancy disparities are complex and remain poorly understood. A recent comprehensive review of the literature of programs and intervention studies specifically targeting AI/AN males revealed a virtual absence of data. The research that would lead us to better understand the causes of inequality, and test approaches to address them, has simply not been undertaken.  Existing evidence suggests that social determinants such as historical trauma, loss of social roles and cultural connection, poverty and unemployment may have greater adverse health effects on AI/AN men than women.  But to date, no effective, overarching efforts to study the root causes and develop AI/AN male-focused interventions to support better health outcomes have been put forward.

Despite this discouraging history, now is the most opportune time to address AI/AN male health disparities and break the cycle of suffering.

The first step to realizing these outcomes is increasing awareness.  Toward this goal, a two-pronged media approach is being coordinated under the auspices of the Men's Health Network - beginning with the production of a series of awareness-building Webinars targeting public health professionals and interested stakeholders at all levels. Entitled Partnering for Wellness: Charting a Course to Hope, Healing, and Health for Native Males and Their Families, the initial Webinar of this series will be presented during Men's Health Month on June 13 at 1 p.m., and will provide an overview of the magnitude and nature AI/AN male health disparities. Follow-up Webinars will explore more specific topic areas relating to the health disparities of Native Males (including Native Hawaiian and Pacific Islanders), outline emerging best practices, explore opportunities to systematically target and test approaches to reach Native males more effectively, and identify needed advocacy.

Join us for the June 13 webinar , Partnering for Wellness: Charting a Course to Hope, Healing, and Health for Native Males and Their Families. No pre-registration is necessary.

As Dr. David Gremillion of the Men's Health Network said: "There is a silent health crisis in America. On average, American men live sicker and die younger than American women."  But we're not talking about it.

On Thursday, June 13, Washington, DC-based Community Education Group (CEG) aims to get folks talking about men's health with the launch of the Back to Life (BSL) Blue Ribbon Campaign. Building on National Men's Health Week, the campaign will provide thousands of Blue Ribbons throughout the District of Columbia to increase the awareness of the high rates of heart disease, cancer, stroke, HIV/AIDS and suicide faced by African American men, and especially those men returning from a correctional setting.

CEG works to reduce the spread of HIV and eliminate health disparities among District neighborhoods by emphasizing education, testing and training for community health workers. Back to Life (BSL) funded by the Office of Minority Health, addresses the gaps in available health care, social and supportive services for high-risk minority families who are living with HIV/AIDS or who are at-risk for HIV infection. The program, which primarily serves Washington DC's Ward 7 and Ward 8, encourages men to seek regular medical care/services and early screening.  These predominantly low-income and medically underserved communities - like many urban communities across the nation - face high rates of HIV Infections, substance abuse, unemployment, low literacy, mental health disorders and imprisonment, to name a few.  In 2012, an average 2,000 District residents returned from federal prisons and 14,000 returned from the DC Department of Corrections (DOC) facilities - 27 percent of them returned to Ward 7 and 23.1 percent returned to Ward 8.

Washington, DC, is the only U.S. jurisdiction that does not have a prison within its borders. Residents charged with a felony conviction are placed at Federal Bureau of Prison (FBOP) facilities across the nations -as far away as California, Oklahoma, New Jersey, Florida, North Carolina and Ohio. Upon returning home to the District, many residents often fall through the cracks in the safety net.

Back to Life (BSL) has developed a comprehensive and coordinated system of care that includes the DOC, Federal Bureau of Prisons, Courts Services and Offender Supervision Agency, Family Medical Counseling Services, Unity Health Care and many other community-based organizations to serve those men returning from corrections settings. Through a family-centered, integrated health and social service network approach with the goals of reducing HIV infections, increasing linkages to care for HIV positive individuals, and improving the overall health of the community, Back to Life (BSL) works to eliminate a major barrier to health care encountered by many District residents returning from prisons, Back to Life (BSL) conducts outreach services to identify these men and provides linkage for these men to needed medical and social services.  Additionally, the program conducts counseling, testing and referral (CTR) services, HIV treatment adherence counseling and linkages to substance abuse treatment and other support services.

For more information on the CEG's Back to Life (BSL) Blue Ribbon Campaign contact Brandon Armani, Program Associate-Community Education Group at Brandon@communityeducationgroup.org.

Last month marked the third anniversary of the Patient Protection and Affordable Care Act, a landmark effort to make health insurance coverage more affordable and accessible. Among the many provisions guiding health reform, the Affordable Care Act includes requirements to ensure the health care system provides adequate coverage for individuals in need of services for mental and substance use disorders. According to a report from the HHS Assistant Secretary for Planning and Evaluation (ASPE), the Affordable Care Act provides one of the largest expansions of mental health and substance use disorder coverage in a generation.

Starting January 2014, an estimated 27 million uninsured individuals will have access to health insurance, and 25 percent of uninsured adults have a mental health condition or substance use disorder or both. The Affordable Care Act presents critical opportunities to improve access to care for these individuals. Building on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Affordable Care Act ensures that mental health and substance use services for newly covered individuals are provided at parity with medical and surgical benefits. The law also requires all new small group and individual market plans to cover 10 Essential Health Benefit categories, including mental health and substance use disorder services.

Improvements to the health care system will not only benefit individuals with behavioral health conditions, but also other groups who experience health disparities. Racial and ethnic minority populations are disproportionately uninsured, face systemic barriers to health care services, and often receive lower quality care and experience worse health outcomes. A concerted effort is needed to ensure that individuals from diverse racial and ethnic populations in need of mental health or substance use services are able to benefit from the expansion of coverage offered by the Affordable Care Act.

As the open enrollment period for the Health Insurance Marketplace approaches, targeted approaches for outreach and enrollment of diverse populations will be critical to reaching these vulnerable groups. The Office of Behavioral Health Equity at SAMHSA has partnered with four national associations (National Asian American Pacific Islander Mental Health Association, National Council on Urban Indian Health, National Latino Behavioral Health Association, and National Leadership Council on African American Behavioral Health) to identify and support the implementation of culturally appropriate outreach and enrollment practices, with the goal of increasing health insurance coverage among diverse populations.

Improved coordinated care and the integration of primary and behavioral health care, supported by Affordable Care Act provisions, will also benefit minority populations in need of mental health or substance use services. Individuals from racial and ethnic minority groups are more likely to seek services from primary care providers; therefore, integrated care models can increase access to behavioral health services. Coordinated care also offers the potential to provide improved services for prevention and early intervention. SAMHSA funds the Primary and Behavioral Health Care Integration program, to provide support to communities to coordinate and integrate primary care services into publicly funded, community-based behavioral health settings, resulting in improved access to primary care services; improved prevention, early identification and intervention to reduce the incidence of serious physical illnesses, including chronic disease; increased availability of integrated, holistic care for physical and behavioral disorders; and better overall health status of clients.

Through these provisions and an emphasis on reducing health disparities, the Affordable Care Act presents critical opportunities for making access to health care more affordable for diverse populations. Now as the federal government partners with communities, we can work together to ensure these opportunities become a reality.

Alejandra was born when I was eleven years old. She’s sassy, smart, beautiful, but first and foremost, my baby sister. Our two older sisters and I have done our best to keep her safe and healthy. Today, Alejandra is attending Kaplan College in southern California, on her way to becoming a patient care technician and, someday, a nurse practitioner. As a soon-to-be health care professional, she has certain medical requirements for the school year; when she went to the doctor’s office, she sent me a text message that said, “I paid $300 by myself. For a checkup and some shots.” It’s Alejandra I think about when I consider the importance of the Marketplaces launching this October.

If you’re a young person like Alejandra, you might not be thinking a lot about health insurance—until the day you need it.  You’ve got other priorities.  But what if you get into an accident, are diagnosed with a serious illness, or have certain medical requirements for school or work? Today, Alejandra knows firsthand the importance of health insurance, and what it means for her and other young adults across the country.

The Affordable Care Act is expanding affordable health insurance options for young adults in several ways.  If you’re under 26, you can now be insured as a dependent on your parent’s plan, with a couple of exceptions — for instance, if you are eligible for your own job-based coverage. Also, new health plans must now cover many critical preventive services at no out-of-pocket cost.  The $300 bill Alejandra paid for her checkup; That could’ve been free.

And there’s more. When the new Marketplaces open for enrollment in October for coverage beginning as soon as January 1^st, 2014, individuals and small business owners will be able to compare their options for buying health insurance and find the quality plan that best fits their budget. The Marketplaces will be competitive, transparent, and simple to navigate—and while you’ll be able to shop for coverage over the phone or in person, if you’re like Alejandra, you’ll probably prefer to check out your new options online through the easy-to-use Marketplace website, healthcare.gov.

Of course, if Alejandra needs help navigating the application, she’ll have it.  And if she needs help paying for coverage, she’ll have help with that too.  If you make less than $45,000, and your job doesn’t offer affordable coverage, you may get financial assistance to help pay for insurance. Another option, if you make less than $15,000, may be Medicaid, which will be expanding in many states beginning in 2014.

Alejandra, like so many other young adults across the country, is just trying to make something of herself. She’s doing her best to make ends meet in order to take that next step in life. Fortunately for my sister, she’ll have one more tool to ensure her long-term health and financial stability – affordable health coverage. Open enrollment in the health insurance marketplace begins on October 1, 2013, and it can’t come soon enough for Alejandra and millions of other young adults in need of health coverage.

I hope all of us who are big sisters, brothers, friends, or neighbors can help spread the word about this great opportunity. I know I will.

Gathered in the parking lot of my hometown church, family and friends were "catching up" with each other before leaving the annual "Homecoming" service and dinner. While in the parking lot, I overheard a conversation between two cousins. One was sharing that she had attended two funerals the day before, and her husband had been ill for several months. Caring for her husband, maintaining a full-time job outside the home and responding to the needs of her adult children and grandchildren had taken their toll on her physically and emotionally. She also commented that she was experiencing back pain but decided it was only arthritis. In this cultural context, arthritis is a minor, recurring and mostly annoying pain that is associated with aging. She had recently celebrated her 51st birthday. Her cousin asked if she had gone to see the doctor about the pain in her back, and she replied, "No, I just didn't want to hear any more bad news."

Back in Atlanta, I attended a high school basketball game and sat beside the uncle of one of the girls on the dance team that would perform at half time. He knew I worked at CDC and was curious about my work at the agency. I described our focus on eliminating health disparities, and this ultimately led to a conversation about a health issue he was having. He told me that for several months, he had been seeing blood in his stools. He was very concerned, and wondered if it might just be hemorrhoids. I asked if he had gone to see a doctor about this, and he said, "No, I just don't want to hear any bad news."

While conducting research several years ago with black men with type 2 diabetes, I was referred to a man who was experiencing multiple symptoms of diabetes but declined to be tested. I asked why he didn't want to know if he had diabetes, and his response was "it's not a good time to know." "Why isn't it a good time?" I asked, and he said, "I'm taking care of my elderly parents, the economy isn't good and it's just not a good time to know." I told him that if he in fact had diabetes, it was better to know and take action to control it. He didn't say anything, but got into his car and drove off. I don't know if or when he was ever tested for type 2 diabetes.

As a medical anthropologist, I am always interested in these types of arguably anecdotal statements made in unsuspecting community contexts to help explain why despite the progress our nation has made over the past 50 years, racial and ethnic minorities still lag behind the general population on many health fronts. We know that communities of color are less likely to get the preventive care they need to stay healthy, are more likely to suffer from serious illnesses, such as diabetes, heart disease and colon cancer, and are less likely to have access to quality health care.

But now, preventive services, consumer protection and other reforms under the Affordable Care Act are giving millions of Americans of all ages, races and ethnicities more value for their health care dollars and contributing to the slowest growth in health care costs in 50 years.

The Affordable Care Act is already making prevention more affordable and accessible for all Americans by requiring health plans to cover many preventive services for free. For example, new health plans must offer no-cost coverage for services that will prevent and control these diseases, like:

• Screening for obesity, and counseling from your doctor and other health professionals to promote sustained weight loss, including dietary counseling from your doctor.
• Blood pressure screening, and counseling on the use of daily aspirin to reduce the risk of a stroke.
• Tests to screen for high cholesterol and diabetes to reduce the chances of developing heart disease.

So how do we work together to ensure that more people actually use and benefit from these services? Achieving the goals of the Affordable Care Act is a shared responsibility between health care and public health practitioners, policymakers, employers and the community. A full discussion of strategies that can bridge the availability of services with persons needing those services is beyond the scope of this blog; however, there are places to begin, such as:

• Mobilizing state and local health departments, community-based organizations, voluntary health organizations and other community resources to implement what has been learned through research and practice about patient activation and patient and family engagement to increase utilization of health services among people who have not previously had access and must now learn how to navigate the health care system;
• Engaging Community Health Workers and Patient Navigators;
• Ensuring a diverse and culturally competent workforce;
• Creating prevention messages that encourage the use of preventive services in ways that leave people feeling empowered by the decision to take advantage of these services rather than "not wanting to hear any more bad news;"
• Acknowledging and addressing the social determinants of health, and the disruptions that come when there is a diagnosis of a life-threatening disease (e.g., new demands on one's time, attention, and finances; new uncertainties about the future; yet another thing to manage) among people whose lives are already stressed and vulnerable;
• "Reaching in" to communities of color and collectively working to change the community conversation to one that promotes wellness and believes we can prevent disease.

How will you implement and benefit from provisions in the Affordable Care Act to achieve healthier communities?

References:
Lasser, K.E.,Murillo, J., Lisboa S., et.al. Colorectal Cancer Screening among Ethnically Diverse, Low-Income Patients. Arch Intern Med. 2011; 171(10):906-912.
Carman, K.L., Dardess, P., Maurer, M., et.al. Patient and Family Engagement: A framework for understanding the elements and developing interventions and policies. Health Aff February 2013, vol 32(2):223-231.
Hibbard, J.H., Greene, J., Becker, E.R., et.al. Racial/ethnic disparities and consumer activation in health. Health Aff September 2008, vol 27(5):1442-1453.
Hibbard, J.H., Greene, J. What the evidence shows about patient activation: Better outcomes and care experiences; Fewer data on costs. Health Aff February 2013, vol 32(2):207-214.
Cooper, L.A., Powe, N.R. Disparities in patient experiences, health care processes, and outcomes: The role of patient-provider racial, ethnic, and language concordance. The Commonwealth Fund. July 2004.
Cleland, J.G.F., Ekman, I. Enlisting the help of the largest health care workforce – Patients. JAMA, September 22/29, 2010, vol 304(12):1383-1384.

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