Excerpted from: Louis Saddler and Andrew B. Whitford, Minority Health in the United States: Why Organization Matters, 8 Journal of Law in Society 105 (Summer, 2007) (16 Footnotes Omitted) (Full Document)
Over the past decade, an enormous amount of research and analysis has taken place regarding racial health disparities, race in health care provision, and socioeconomic determinants of public health outcomes in the United States. The U.S. Healthy People 2010 guidelines have two goals: (1) to increase quality and years of healthy life; and (2) to eliminate health disparities. The U.S. Department of Health and Human Services (HHS) has selected six areas of serious racial health disparities for the focus of its efforts. The selection was made on sound technical grounds: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infections/AIDS, and immunizations. Major funding organizations have established programs to eliminate racial and ethnic disparities in health care and outcomes; the Robert Wood Johnson Foundation alone has provided over $23 million in funding.
Our position is that the organizational structure of minority health resources and advocacy at the federal level in the United States limits the gains that can be made toward reducing American health disparities and perhaps even exacerbates problems associated with differential treatment and incidence of health conditions among American minority and ethnic groups. In this paper, we compare and contrast the two organizations within HHS that are most responsible for representing the interests of members of minority and ethnic groups ù the Office for Civil Rights (OCR) and the Office of Minority Health (OMH). Our purpose is to evaluate their ability to coordinate efforts with other organizations and agencies in the pursuit of eliminating health disparities. Our claim is that despite recent changes to OCR's mission, the two share a core mission and act as leaders in elaborating and leading HHS health disparities initiatives, and that their separation reveals two, perhaps competing paths toward eliminating disparities. The question is: does it make sense for OCH and OMH to remain separate agencies? This is an important vignette for how large, complex democracies try to eliminate health care disparities in the twenty-first century ù one that can provide lessons on how to reconcile research about best practices within the administrative reality.
We first introduce these organizations' histories and characteristics, and then turn to a discussion of their initiatives.
Finally we examine their similarities and differences, and discuss advantages and disadvantages of their separation.
The American Organization of Minority Health
HHS is responsible for protecting and promoting good health for all Americans and providing them with essential human services. HHS manages over 300 programs and 60,000 grants covering activities in public health, income support, basic and applied science, and child development. Created in 1953 as the Department of Health, Education, and Welfare, HHS is the largest department and makes up almost 25 percent of all federal outlays. The greatest expansion in HHS came in 1965 with the enactments of Medicare for hospital insurance for the elderly, and Medicaid for medical aid for the poor. In 1979 Congress removed education functions from HEW; it was renamed HHS. Its four operating divisions are the Administration for Children and Families (ACF), the Public Health Service (PHS, which includes the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes), the Centers for Medicare and Medicaid Services (CMS), and the Administration on Aging.
HHS is the main federal entity responsible for addressing racial and ethnic health disparities in health care, particularly minority health access. Its projects, programs, and research are often coordinated with the efforts of other agencies, researchers, and private organizations. Possible interventions include management programs, disease prevention programs, health literacy and language service projects, and education and outreach programs. The two offices responsible for obtaining these goals are the Office for Civil Rights and the Office of Minority Health which both report directly to the Office of the Secretary.
Office for Civil Rights
The Office for Civil Rights (OCR) is the primary advocate for the public's right to nondiscriminatory access to and receipt of health and human services from hospitals, nursing homes, Head Start centers, and other entities under HHS' service umbrella. This entails promoting and insuring the enforcement of laws and regulations prohibiting discrimination based on race, age, color, national origin, disability, sex, and religion. OCR has a director, principal deputy director, general counsel, 3 deputy directors, and 10 regional offices located throughout the United States. OCR is comprised of three groups ù compliance, legal counsel, and program management.
Specifically, OCR assesses compliance with nondiscrimination and privacy rule requirements by processing and resolving complaints. OCR also conducts pre-grant and preventative compliance reviews; pre-grant reviews are conducted when facilities seek approval to participate in the Medicare program, and preventative compliance reviews examine the compliance status of a program recipient after receipt of HHS funds. Issues raised include civil rights concerns not focused on high priority activities. Notably, OCR also now enforces the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA), but only uses these mechanisms in the case of possible civil rights violations and not in HIPAA enforcement. The compliance division is responsible for monitoring corrective action plans and carrying out various OCR-initiated compliance activities such as training, community outreach, voluntary compliance, technical assistance, and consultation activities; it is also responsible for receiving, responding to, and investigating complaints alleged possible compliance violations. In contrast, legal counsel prepares cases for administrative enforcement, assists the Department of Justice in litigating court cases involving civil rights issues or HIPAA, and developing civil rights and privacy regulations. Program management provides overall policy and program direction, establishes compliance priorities, develops short and long-range program plans, and sets measures for program outcomes and staff performance.
Office of Minority Health
In contrast, the Office of Minority Health (OMH) is responsible for protecting and improving the health of racial and ethnic minorities such as American Indians and Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians, and other Pacific Islanders by developing health policies and programs intended to eliminate health disparities. The Advisory Committee on Minority Health helps the OMH establish goals and objectives related to disease prevention, good health promotion, service delivery, and research projects. OHM coordinates those objectives with other activities within the PHS focusing on members of racial or ethnic minority groups. OMH is required to enter into interagency agreements with other PHS agencies and national minority organizations. OMH also supports research, demonstrations, and evaluations testing innovative models improving HHS' ability to conduct research. Other OMH responsibilities include increasing the minority populations' understanding of health risk factors, developing ways for better information dissemination, and service delivery to members of racial or ethnic minority groups, ensuring that the National Center for Health Statistics collects data on each minority group, and supporting a national resource center that focuses on minority health.
OMH was established in 1986 following recommendations developed by the Secretary's Task Force on Black and Minority Health. OMH's original mission emphasized cancer, cardiovascular disease and stroke, chemical dependency, diabetes, homicide, suicide, and unintentional injuries, and infant mortality and low birth weight. It has three divisions: Information and Education, Policy and Data, and Program Operations. The Information and Education division was created when Congress required OMH to have a national minority health research center, which facilitates exchange regarding health information and promotion, preventative health services, and health education. The Policy and Data division is responsible for policy coordination, legislation development, policy research, evaluation, and analysis to better assess the policy needs of minority populations. This division also develops national health goals and objectives. The Program Operations division carries out OMH's day-to-day functions. The division also develops, implements, and conducts pilot or small-scale community-based projects addressing health disparities in local minority communities. In addition the Program Operations division also provides technical assistance, upon request to minority community groups working to establish similar entities within their states. This division is responsible for coordinating with other agencies and organizations to carry OMH's initiatives.
Since OCR and OMH are participants in HHS Disparities Initiatives, their programs and initiatives rely heavily on coordination with other agencies, organizations, and programs for achieving the elimination of minority health disparities. Both organizations seek to carry out enormous mandates. Essentially, these missions and goals create a network of interdependence and coordination among agencies formally known as a team. In organization theory, teams consist of actors with similar preferences, different knowledge, and equally valuable resources who must collectively accomplish a goal or make a decision. A successful team has: (1) a total communication network; (2) members' resources have similar importance for issues; and (3) a common interest or goal. Both OCR and OMH are trying to accomplish this situation in their respective programs and initiatives.
OCR Initiatives: Closing the Gaps in Health Care
A key initiative of the OCR is the “Closing the Gaps in Health Care” program, which focuses on the minority health disparities by addressing both medical bases and social bases (such as discrimination and civil rights issues). OCR mainly provides technical assistance to programs and organizations with similar objectives. They handle issues related to public education and increasing the awareness of civil rights issues in quality health care access among rural at-risk populations (persons with disabilities, African-Americans, Native Americans, and national origin minorities in Southwestern, Midwestern, and Southern states). Specific ways OCR tries to accomplish this include conducting workshops with other agencies or organizations for stakeholders in minority health, including state and local government, health care workers, and minority health researchers and advocates.
One example is the OCR's coordination with the Center for Minority Health (CMH) to conduct the annual National Minority Health Leadership Summit, which encourages minority participation in biomedical and public health research. OCR tries to arrange “teams” in these situations that include stakeholders like CMH, local government, and community groups. OCR builds communications networks for the dissemination of information needed by actors to enhance knowledge sharing so that actors can contribute to the initiative's success. Groups bring similarly important resources to the issue, which enhances interdependence: OCR brings program management and community outreach resources; researchers bring data and research capacity, and local government and community organizations bring participation, support, and information about current issues regarding minority health. Such initiatives will probably fail if any one of these resources is missing. Moreover, the actors share common interests or goals ù here, to produce more minority participation in biomedical and public health research, and more broadly to eliminate minority health disparities.
Children and Families
A second initiative centers on improving and ensuring nondiscriminatory access to Medicaid managed care, State Children's Health Insurance Program (SCHIP) benefits, and Temporary Assistance for Needy Families (TANF) programs. OCR provides technical assistance for making benefit applications, forms, and procedures more accessible to national origin minorities. OCR advises on the modification of policies and procedures and training caseworkers to remove barriers faced by national origin minority children; it also addresses issues of race, color, and national origin discrimination in the context of adoption and foster care.
The question becomes, in what manner should these interdependent actors work together in order to reduce these disparities? This is the problem that OCR is faced with because they must coordinate efforts between Medicaid, SCHIP, and TANF to accomplish these goals. Also, OCR must provide technical assistance to other national and state agencies in order to make their programs more effective. The effort of both OCR and these other programs is an excellent example of the “team production” which is necessary to begin to alleviate these disparities. Political actors, by making decisions about the need to expand minority participation, delegated the discretionary authority needed to accomplish the initiative's goals to a broad group of organizations ù implicitly requiring coordinated efforts between the various agencies in order to achieve the desired outcome. In this case, OCR's role includes making decisions for many types of caseworkers involved in the initiative by passing along decisions as advisement. However, one problem with this design is that the initiative's goal is a desired outcome and not an advisement itself - which has implications on the grading of OCR's performance and the success of its participation.
Limited English Proficiency
Another important initiative focuses on ensuring discrimination does not prevent minorities with low or limited English aptitude from receiving health care and social services from federally-funded programs. While significant research has discussed this initiative, we only briefly review the implications of OCR's structure for this initiative. OCR's task is to coordinate with various HHS agencies ù mainly CMS, ACF, the Health Resources and Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The goal is to maximize existing HHS resources for language assistance and develop initiatives to enhance technical assistance for recipients.
This group of agencies is charged with making collective decisions regarding language assistance. In contrast, other initiatives reviewed above center on agencies' efforts in order to produce a specific social outcome. The key question is how the agencies collectively identify ways to maximize HHS resources for language assistance and develop initiatives to enhance resources and technical assistance. Of course, the agencies are expected to draw from their respective inputs and contribute information that will be helpful in decision-making. More importantly, all have the same importance for deciding appropriate initiatives for solving the problem; in the other initiatives OCR provides a direct leadership role. All of these agencies stand to gain from better serving recipients with low English proficiency. There are few direct conflicts of interest between these agencies. The difficulty is that no one agency can take clear actions that limit discrimination against racial and ethnic minorities with limited English aptitude and reduce disparities in health care and receipt of social services.
OMH Initiatives: Asian-American Pacific Islander Initiative
We now review a select group of OMH initiatives. First, the Asian-American Pacific Islander Initiative addresses health care and health services that are unique to Asian-Americans and Pacific Islanders (AAPIs), as well as issues shared with other minority groups. The goals are to: (1) increase AAPI access to and utilization of health and human services; (2) expand data collection, analysis, and dissemination regarding AAPI populations; (3) expand funded research projects and programs targeted towards AAPIs; (4) increase AAPI outreach and participation in training programs; (5) ensure that AAPI health issues are addressed by other HHS operations; and, (6) enhance the capacity of HHS agencies to serve APPIs. This initiative's success will depend heavily on developing productive collaborative efforts between OMH and other HHS agencies. More importantly, achieving these goals depends on developing productive working relationships with AAPI community-based organizations.
Like some OCR initiatives, this initiative will turn on OMH's ability to change social outcomes not through its own actions, but through guiding the actions of an inter-agency production team. This program's goals on aspects of health care and health services unique to Asian Americans and Pacific Islanders require the involvement of huge number of actors, encompassing diverse areas within HHS; like OCR, OMH faces difficulty in controlling the joint production of these social outcomes by a group of agencies with large size and broad composition.
Hispanic Agenda for Action
This initiative is meant to ensure that HHS programs and services are reflective of and sensitive to Hispanic customers. Its goals are to: (1) enhance HHS capacity to serve Hispanic Americans, (2) implement Executive Order 12900 on education opportunities for Hispanic populations, (3) ensure data regarding Hispanic populations are accurate and adequate, (4) develop a Hispanic health agenda, (5) foster closer collaboration among operating divisions of HHS, and, (6) eliminate language barriers prohibiting Hispanic customers from receiving HHS programs and services. Senior officials must ensure action plans for this initiative are submitted and reviewed, as well as make sure clear timetables are agreed to and monitor progress; a Hispanic Steering Committee also reviews progress.
As with other initiatives reviewed here, OMH's problems are to make decisions about needed programs and services, and then obtain the agreement of other HHS agencies for achieving those priorities; decision-making and production are separated, so OMH is in the unenviable position of obtaining accord by agencies not actually involved in setting goals ù even if those agencies agree with the broad need for programs and services more reflective and sensitive to Hispanic customers. How can OMH obtain those goals when other agencies control the capacity to do so?
Historically Black Colleges and Universities (HBCU) Initiatives
Created in 1993 by Executive Order 12876, the purpose of this initiative is to encourage increased minority participation in biomedical and public health research. The broad goals include: (1) increasing HBCU participation in HHS research and evaluation activities; (2) creating options for HBCU students through internships and mentoring; (3) fostering information exchange between HBCUs and HHS; (4) increasing HBCU capacity to address the needs of families and service providers in leadership, skill building, and information dissemination; (5) increasing HBCU faculty participating in departmental review groups, task forces, and committees; (6) increasing HBCU capacity for addressing research on health disparities and training minority health and mental health professionals and researchers; and, (7) fostering partnerships between HBCUs and other higher education institutions. This initiative has participation from a majority of the divisions within HHS due to its wide range of activities.
This initiative is an exemplar of OMH's core role in expanding discussion and information exchange within HHS, and between HHS agencies and external stakeholders. The problem for OMH is to manage information flows so that participating agencies, HBCUs, and other groups benefit from having a clear communication network; this is especially tricky when the initiative's purpose is to expand membership well beyond the point where clear and coherent information flows break down. As membership becomes larger, organization theory suggests that OMH will inevitably find it more difficult to serve as a source of “control” ù making clear communication even more important. This presents a dilemma for OMH: unfortunately, the large number of actors involved only increases chances for error transmission; while clear communication can help limit errors, the size of the group itself limits OMH's ability to do so.
We want to be very clear that regardless of recent attention on HIPAA, OCR and OMH continue to share so much in common that they appear to have the same basic mission. Evidence of this is that they pursue almost the same initiatives. Excepting HIPAA, OCR initiatives center on minority health disparities from a medical and social standpoint, improving minority access to HHS programs, and ensuring that persons with limited English proficiency receive nondiscriminatory service. OMH initiatives are almost identical, although there are differences in naming. A second similarity is how the agencies are structured. OCR consists of three divisions ù compliance, program management, and legal counsel; OMH consists of three - Information and Education, Policy and Data, Program Operations. OCR's compliance division is almost equivalent to OMH's Division of Information and Education, and OHM's Program Operations is almost equivalent to OCR's program management; yet, OCR's legal counsel and OMH's Division of Policy and Data differ. This reveals an important separation in programmatic authority: OCR's legal orientation versus OMH's analytic capacity.
OCR and OMH also have their differences ù for example, their scope of work. OCR's targets are somewhat broader while OMH is more specific with its initiative targets (as seen by race-specific initiatives), although OCR's programs on limited English proficiency call into question the degree to which scopes are different. Another difference is the manner in which they go about accomplishing overall missions. For OCR, eliminating minority health disparities is more about ensuring programs and providers are compliant with civil rights legal frameworks, but OMH is more proactive in creating opportunities and mechanisms for eliminating minority health disparities.
After considering their similarities and differences, does it make sense for these two agencies to be combined into one? Given HHS' new role as an adjudicator of privacy rights as civil rights, should OCR remain separate? Should OMH be made a part of OCR? Combination might strengthen the two and further the goal of eliminating health disparities among racial and ethnic populations. At a minimum, OCR's data utilization might improve given OMH efforts regarding service for target groups; or would OCR be better off casting a wide net of solutions that only help a handful of people? OMH might benefit from OCR's interests in obtaining compliance. And of course, the efficient use of resources is a common reason for reducing redundancy and consolidating operations. Is it a waste for two organizations with such overlap in their missions to differ mostly in terms of their names? To help us move toward answering these questions, we close with two simple observations that we believe speak volumes about how the American response to minority health disparities is currently organized. Our first observation is this: is HIPAA now OCR's core mission, and if so, what is the cost in terms of reducing minority health disparities? Second, in the end, will OMH be able to achieve much regarding eliminating minority health disparities when it lacks OCR's capacity to seek compliance and legal redress? Will OCR be able to do much without OMH's analytic capabilities?