Primary Care Access Fuels Columbia Health Disparities
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This has been reprinted with permission from the Columbia Missourian on May 22, 2018, written by Alexis Allison with input from Community Commons.
When Verna Laboy goes over the paperwork for black residents in a local health program, it’s what she doesn’t see that gives her pause.
In the space where there should be a primary care provider, there’s no name written. Instead, she finds again and again, “N/A.”
Laboy, a health educator at the Columbia/Boone County Department of Public Health and Human Services, knows “not available” doesn’t accurately describe the local primary care landscape. Boone County has one of the best ratios of primary care physicians to residents in the state, according to County Health Rankings and Roadmaps, a program that annually measures health at the county level.
And then there’s Columbia, touted as a city that brims with health care providers, thanks to the presence of a bustling medical school and residency program, as well as multiple hospitals and clinics.
And yet, availability does not guarantee access — especially for the city’s low-income and black residents, whose lack of established primary care can contribute to worse health and shorter life expectancy.
“We see disparate access particularly for people of color,” said Steve Hollis, human services manager at the Columbia/Boone County Department of Public Health and Human Services. “We know from state-level and county-level data that there tends to be a lower insured rate in that population.”
Primary care is the first line of care a patient seeks to address the majority of health problems, from colds to chronic diseases. Primary care doctors work in a family or community setting and develop a long-term relationship with their patients, according to the National Academies of Sciences, Engineering, and Medicine. An appointment with a primary care doctor might include regular check-ups, screenings and vaccinations — which help identify and address chronic diseases such as heart disease, cancer and diabetes that disproportionately affect Boone County’s black residents.
The disparities begin in the womb. Between 2011 and 2015, about 15 percent of black babies in Boone County were born with low birth weight, or under 5.5 pounds, according to Missouri Department of Health and Senior Services. For white babies, that number was only about 6 percent. According to March of Dimes, babies born with low birth weight may be more likely to develop chronic diseases such as diabetes or heart disease later in life.
The rate of death from heart disease for Boone’s white residents was about 146 per 100,000 people per year, according to 2005-2015 data from the Missouri Department of Health and Senior Services. For black residents, it was about 256, or 1.75 times higher. The rate of death from various cancers for Boone’s white residents was about 164 per 100,000 people per year. For black residents, it was about 216, or 1.32 times higher. When it comes to diabetes, the overall rates were lower, but the disparities were greater. Black residents died from diabetes at a rate of about 62 per 100,000 people per year, almost four times higher than the rate for white residents, which was just less than 17 per 100,000 people.
Chronic diseases are the leading cause of death in the United States, according to the Centers for Disease Control and Prevention.
“There does seem to be a correlation between regular primary care and better health outcomes,” Hollis said.
In other words, people who can point to a primary care doctor as their source of care tend to be healthier.
The barriers to developing a relationship with a primary care doctor include a lack of awareness of available resources, transportation to and from appointments, flexible work schedules that allow for regular check-ups and health literacy. But ultimately it boils down to cost.
“It’s almost purely an economic issue,” Hollis said. “The bottom line is the cost of care. And it used to be uninsured people, but now it’s even folks that are insured … You can’t get to those (other issues) if people don’t perceive the care to be affordable.”
Health and economic mobility
The relationship between health and wealth isn’t linear. Instead, it’s like a web with multiple entry points — each component can be a cause and an effect, a catalyst and a consequence. In other words, studies suggest that good health may contribute to upward economic mobility, or the ability of people to increase their income and economic status, according to the Urban Institute. On the other hand, a higher socioeconomic status may contribute to good health.
“The reality is that most of us aren’t great about preventive care, and we wait until we’re sick,” Hollis said. “If you have insurance and social capital and health literacy and social power, you’re able to get into a primary care provider more quickly.”
However, low-income populations may not have margin in their budget to invest in regular health care. An adult working full-time in Boone County with no dependents must earn $10.64 per hour to maintain a normal standard of living, according to MIT’s living wage calculator. The minimum wage in Missouri is $7.85 per hour.
“People are going to pay their rent and utilities and food first. Unless they’re in dire circumstances, then the health care seems to come last,” Hollis said.
Once a health problem can no longer be ignored, people turn to the emergency room or urgent care. Patients with a lower socioeconomic status tend to use these services more than their wealthier counterparts, according to a 2013 study by the Robert Wood Johnson Foundation. Black people are more likely to have gone to the emergency room at least once in a 12-month period than their white counterparts, according to a 2010 brief from the National Center for Health Statistics. For some, these services actually become their primary care providers. The problem is, the emergency room and urgent care aren’t designed for that role, Hollis said.
But local options have stepped in to address access to primary care for low-income residents.
Family Health Center in Columbia is a federally qualified Health Center, which means that it receives funds from the Health Resources and Services Administration for providing services to underserved populations. The center’s offerings include primary, mental health and oral care, as well as services meant to increase access, according to its website. For patients who don’t speak English, the center provides interpreters. For patients who require specialty care, the center provides referrals. For patients who just can’t get to an appointment, the center provides transportation. And all of this is provided on a sliding scale, so patients who earn less, pay less.
For uninsured and under-insured locals, the Family Health Center may become the primary care provider. But despite its sliding scale fee system, not everyone can afford an appointment. The center’s co-pay, or fixed out-of-pocket amount paid by the patient, can be discouraging, according to Stephanie Browning, director of the Columbia/Boone County Department of Public Health and Human Services.
“If you can’t make the co-pay, you’re probably not likely to make the visit,” Browning said.
For those who can’t afford the Family Health Center, they can find ongoing primary care at MedZou Community Health Clinic. MedZou is a faculty-sponsored, student-led clinic operated through MU’s School of Medicine that provides free primary care for uninsured adults.
“The idea here is that most of these patients have ongoing medical care needs, so they have chronic conditions or complex conditions like diabetes that need to be managed,” Jen Coffman, MU Health Care spokesperson, said. “It’s not walk-in acute care — it’s really to establish a medical home where they have continuity of care.”
The primary care clinic takes place year-round from 5 to 9 p.m. on Thursdays, and specialty care clinics take place during the same time period on most Mondays, according to MedZou’s website. The latter includes diabetes care, skin care and neurological care, among other services, on a rotating schedule.
Like the Family Health Center, MedZou offers interpreter services for patients who don’t speak English. However, its hours of operation can make attendance difficult for patients who work evenings.
“Everyone is a volunteer, so they really are limited to the Mondays and Thursdays,” Coffman said.
The Department of Public Health and Human Services likewise has been working to address the community’s health needs, outlined in its initial Community Health Improvement Plan from 2014. After developing five teams to carry forward its plan, the department faced its own share of barriers, also related to cost of care. The Access to Health Care team, one of the five, has stopped formally meeting.
When the teams were being developed, the state hadn’t decided whether to expand Medicaid coverage. The planning for the Access to Health Care team was predicated on the idea that Missouri would expand, Hollis said.
The team ran into more challenges on the ground. The Family Health Center and MedZou were already providing free or reduced-price care, and when the state decided not to expand Medicaid coverage, some local residents simply didn’t have the financial resources to prioritize preventive care among their other obligations, according to Rebecca Roesslet, a public health planner at the Columbia/Boone County Department of Public Health and Human Services.
“The work group was challenged with what activities … we could move the needle on in Boone County,” Roesslet said. “It wasn’t that we felt the issue was no longer of value, it’s that we found we had very little traction in our ability to improve access to care in our community.”
Live Well By Faith connects to community
Providing information about which programs do address access to care, and about preventive health practices such as nutrition and exercise, is Laboy’s bailiwick. She leads Live Well By Faith, a program set primarily in local black churches that addresses intentional and healthy lifestyle choices among the black community.
“We target the churches because, historically, any movement that made a difference with this population, the foundation, the root, the start, the launch, was in the black church,” Laboy said.
Live Well By Faith launched in 2016, funded by a grant from the Boone County Commission. Since, it has grown to offer seven programs on a rotating basis, all of which address the specific health care concerns of the local black population. Among those, there’s the African heritage cooking class, a diabetes self-management class, a nutrition and fitness class through MU Extension and a weight-loss competition. The majority of the classes are free.
For Laboy, a self-proclaimed “health evangelist,” one of her main pursuits is changing the narrative of poor health in the black community.
“It’s almost like bad health is expected,” Laboy said. She said she’s working with a population of people who’ve become accustomed to feeling bad.
“And it’s almost like they’ve given up,” Laboy said. “So even though there might be resources like the Family Health Center and Medzou, it’s not even on their radar to look for health because they’ve given up.”
Laboy’s job is to put health on the radar. The weight loss competition is about to begin for the third season, and this time around, she has a new strategy: meet personally with any program participant who doesn’t have a primary care provider.
She’ll counsel them to find one, or to connect with the Family Health Center — whatever it takes, so every person who joins Live Well by Faith knows those options exist. They can establish a primary care home. The answer no longer has to be “N/A.”
In the end, Laboy can’t provide her patients with a living wage job or health insurance. She can’t lower the cost of care, or erase the disparities that have previously affected the people with whom she works — but she can help rewrite the narrative of poor health in that community.
“It’s getting people to believe in themselves and value themselves,” Laboy said. “You can’t pursue your dreams if you’re sick.”