Implementing Solutions to Health Care - The Empire State Medical

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					     “Closing the Gap:
Implementing Solutions to
Health Care Disparities in
       New York”

           Daniel Laroche MD
   Empire State Medical Association,
NYS National Medical Association affiliate
   Assistant Professor Ophthalmology
       New York Medical College
    New York Eye and Ear Infirmary
President, Advanced Eyecare of New York
AMA History with respect to Black
   1870: The integrated National Medical Society delegation was
    excluded from the AMA Annual Meeting in Washington, D.C.
   1874: The AMA adopts a system of governance allowing state medical
    societies to determine which local societies will be recognized at AMA
    meetings, effectively allowing each state to decide the question of
    racial segregation.
   1910: The AMA-requested Flexner Report, Medical Education in the
    United States and Canada, is published; the report recommends that
    all but two black medical schools be shut down.
   1939: The AMA discontinues its policy of listing black physicians as
    "colored" in its American Medical Directory. The House of Delegates
    adopts policy discouraging racial discrimination in constituent society
    membership but allows it to continue.
   1965-1968: The National Medical Assn. and the Medical Committee
    for Human Rights picket the AMA's meetings, protesting the
    Association's lack of action on state and county medical societies'
    racial exclusion policies.
    American Medical Association
        Apology, July 2008
   The American Medical Association officially apologized in July
    for its history of excluding black physicians from membership,
    for listing black doctors as "colored" in its national physician
    directory for decades, and for failing to speak against federal
    funding of segregated hospitals and in favor of civil rights
   "The AMA failed, across the span of a century, to live up to the
    high standards that define the noble profession of medicine,"
    said AMA Immediate Past President Ron Davis, MD,
     – Journal of the American Medical Association.

        July 2007 Hawaii                  July 2008 Atlanta
Some Progress has been made
   There are about 48,000 physicians in New York State
   About 3,024 are self described as Black non Hispanic
   Population of New York is 9 million with a Black population of
    1.8 million
   White physician/patient ratio is 1/150
   Black physician/patient ratio is 1/595
 Study on Black Physicians in NY
        The number of Black physicians has not increased
substantially over the past decade and remains far less than
 their corresponding proportion in the state’s population.
        Black physicians are more likely to practice in a primary
care specialty and work in hospitals and clinics. They are also
more likely work in areas of the state that are federally
designated as primary care shortage areas.
        Black physicians, improve the diversity and cultural
competency of the physician workforce, can increase access
 to care and quality of care for underserved populations in
New York
Study on Black Physicians in NY
   Black physicians were more likely to serve a higher percentage of
    Medicaid patients in their practices compared to all other
   About one-third of Black physicians reported patient case loads of
    at least 50% Medicaid patients compared to slightly more than
    11% of all other physicians.
   There continues to be a tremendous shortage of Black physicians
    in New York State

    Source: NYS Education Department Physician Re-licensure Survey
    The Center for Health Workforce Studies
 Cardiovascular Disease
 Blacks in NY are
  55% more likely to
  die of heart disease
  compared to whites
  at ages 45-54
    Cardiovascular Disease
   In the last 15 years heart disease hospitalizations increased in
    excess of 40% in eight mostly low-income neighborhoods:
     – Especially in Brooklyn
         • Increase of 94.4% in East New York
         • Increase of 78.5% in Bedford Stuyvesant-Crown Heights
         • Increase of 56.2% in Flatbush-East Flatbush
 Black New Yorkers are
  46% more likely to die
  from cancer than
                               Gregory Hines
  whites ages 45-54            Famous
                               Tap Dancer
                               Died of liver cancer
                               At age 57

                               Ben Carson
                               Prostate Cancer
Breast Cancer

 The incidence of
  Breast cancer is
  over 40% higher
  among white
  women however
  more Black
  women die from
  Breast Cancer

                     Breast Cancer Stamp
 In NY, 20% blacks
  suffer from diabetes
 In the last 15 years
  hospitalizations have
  doubled in
  – South Bronx
  – East Harlem           In 2005 the costs of an additional
  – Central Brooklyn      3,100 hospitalizations in the
                           bottom two sixths neighborhoods
                          was $37 million. Much of it paid by
                           the public through Medicaid or
                          hospital charity pool.
 50% of Black women are
 This increases risks for
  hypertension, heart
  disease, diabetes.
 Black high school
  students in NY report
  the lowest rate of
  physical activity (over
  past 7 days), but the
  highest rate of
  television watching of 3
  or more hours per day.
   50% of AIDS-related deaths in
    the city occur among blacks,
    who account for 25% of the
    city's population.
   In addition, black women
    account for 34% of the city's
    new AIDS cases
   Approximately one in five
    black men ages 40 to 49 living
    in the city is HIV-positive
   Statewide, girls and women
    account for 48% of new HIV
    cases among people ages 13
    to 19, and HIV prevalence
    among black women is more
    than 27 times higher than
    prevalence among white
   Black high school students
    report the highest rate of
    sexual intercourse and of
    forced sexual intercourse
    among female students

New York City Department of Health and Mental Hygiene
   In NY, children in poorer
    neighborhoods are 3x as
    likely to be hospitalized for
    asthma than children living
    in wealthy neighborhoods.
   Although the adult
    incidence of asthma are
    similar for Whites, Blacks
    and Hispanics, the death
    rates due to asthma is more
    than four times higher
    among Blacks than it is
    among whites

                                    Rap star Coolio suffers from
                                    Asthma and is a spokesperson
                                    For the Asthma and Allergy
GLAUCOMA                                                             Kirby Puckett had to
                                                                     Retire early from
                                                                     Baseball and loss vision
   Leading cause of blindness                                       In one eye from
    in the African-American and
    Afro-Caribbean community
   Blindness rates from
    glaucoma are 4-6x higher in
    Blacks than whites

                                                                       Ray Charles went
                                                                       Blind from glaucoma
                                                                       At age 6

     Surgical Undertreatment of Glaucoma in Black Beneficiaries of
     Medicare: Archives of Ophthalmology Vol 118, Feb 2000
       Infant Mortality
 In NY in 2006, the
  infant mortality of Black
  babies is 2-3 x that of
          Lead Poisoning
– In the year 2004,
  6,200 children were
  identified with lead
  poisoning, 94% of the
  children are black
– This continues to
  occur despite the fact
  that the NYC Dept. of
  Health banned lead
  based paint over 40
  years ago
       Substance Abuse
 New Yorkers living
  in poorer
  neighborhoods are
  4 times more likely
  to be hospitalized
  for substance
  abuse than those
  that live in wealthier
                  Mental Illness
   Poorer New Yorkers are
    more than 2-6x more likely to
    experience serious emotional
    distress than those with
    higher incomes
   Rate of Mental Illness in
    Fordham and Bronx Park
   Whereas, the rate of Mental
    Illness in wealthier Riverdale
    is 3%
   For Brooklyn, roughly one in every 53
    black 15-year-old males will die from
    homicide before reaching their 45th
   By contrast, the average 15-year-old
    U.S. male faces a very low one-in-185
    probability of being murdered before
    reaching the age of 45.
   Most of this violence is Black on Black
    Violence.urdered before reaching age
   Chance of being a murder victim
     – White female 1:606                                 Councilman
     – White male 1:106                                   James Davis
     – Black female 1:124
     – Black male 1:29

                             WK Kellogg Foundation, CDC
    In NYS the jail budget is
    higher than the state
    education budget
   Costs $40,000 yr to keep a
    prisoner in jail, this is
    enough money for a college
   In Suffolk County NY
    Blacks make up 55% of the
    prison population and only
    5% of the county
   63% of Black jail inmates
    were found to have a
    mental health problem
   Being in jail is the single
    most deterrent to
   What are the Life Expectancy
        and Death Rates?
  Average life expectancy is:
     71.8 years for African Americans
     77.4 years for Whites
  Black Men- 68.3 years
  White Men- 74.8 years
  Black Women- 75 years
  White Women- 80 years
Between 1990 and 2001, black men’s life expectancy increased by nine years and
black women increased by 5 years. Whites increased too by ½ as much
          Disparities in Educational
      New York School districts
       serving poorer and minority
       neighborhoods receive
       $2152 less per student
       compared to school districts
       with fewer poor students
      An average elementary
       school may have 400
       students translating into a
       massive $860,800
      Lack of funding leads to
       lack of teachers, books,

    The Funding Gap: Low- Income and Minority Students Receive Fewer Dollars by the Educational Trust 2002
         Access to Medical Care
 There are two million New Yorkers without health
 Poorer New Yorkers without health coverage are the
  most likely to not receive medical care.
 However even those with private health insurance or
  Medicare continue to have racial/ethnic disparities in
 “Race and income have substantial effects on
  mortality and use of services among Medicare
  beneficiaries. Medicare coverage alone is not
  sufficient to promote effective patterns of use by all
  beneficiaries “
   Marian E. Gornick, M.S., Paul W. Eggers, Ph.D., Thomas W. Reilly, Ph.D., Renee M. Mentnech, M.S.,
   Leslye K. Fitterman, Ph.D., Lawrence E. Kucken, M.P.A., and Bruce C. Vladeck, Ph.D. NEJM Vol
   335:791-799, No. 11, 8/12/96
    Pt Esmin Green Ignored to Death in
       NY Hospital Emergency Room
   HHC President Alan D. Aviles said
    in a statement "It is clear that some
    of our employees failed to act based
    on our compassionate standards of
   NYCLU Executive Director Donna
    Lieberman said at the time "The
    pattern of neglect and abuse at
    Kings County Hospital Center is an
    affront to human dignity,".
   “There over 80,000 black patients
    like Esmin Green that die
    prematurely every year across the
    US due to healthcare disparities and
    lack of cultural competency.“
   How many more deaths will be
    needed to enact statewide
    healthcare reform?
         Shortage of Primary Care
          Physicians in Minority
   In 2004 there were 74 primary care physicians per 100,000
    people in the bottom sixth neighborhoods of health outcomes
   This is compared to 197 primary care physicians per 100,000
    people in the top sixth neighborhoods of health outcomes.
 If we change
  our minds we
  can change
  the times!
 If we change
  our minds we
  can change the

We must all respect each other to prevent the atrocities
and excess deaths from racism and discrimination
       Improve Education by
      Reforming the Classroom
 Smaller class size enables
  more learning
 Provide behavior consultants
  for those children in need
 Comprehensive students
  assessments for those
  having difficulty
 Improve teacher training
 Tie teacher benefits to
  academic improvement in
  test scores
 Preparation for employment
  and good health starts in
         Improve Education
Improve educational protocols in the zip codes with
the highest health disparities: Rationale: Schools like
the Harlem Village Academy Charter
School      should be a model for all NYC public school
education. They have taken 5th graders performing in
the bottom 25% of test scores and turn them around
by the time they enter 7th grade to be in the top 5% of
test scores city wide. They have a rigorous curriculum
grounded in the highest expectations for all students.
A caring and nurturing environment. They teach
students to think deeply, independently, and critically.
They have a longer school day from 7:30 am to 5:30pm
with Saturday school and study hall for students whom
need extra help and attention. They have a culture of
accountability for academic achievement, a clear strict
code of conduct that is consistent throughout the
school and school uniforms that contribute to a culture
of respect, scholarship, and community.
 Blacks armed with a four-year college diploma not
  only are far less likely to be unemployed, but the
  black-white unemployment gap is greatly reduced.
 Employment leads to reduced poverty and greater
  access to healthcare.
 Therefore, the historical two-to-one racial
  unemployment gap is reduced to 1.25-to-one for
  those with a college diploma.

             “US Labor Department, June 2004”
Improve Self Esteem of Youth
 and educate about Academic
        Black Heroes
 Improve the self-esteem of Black youth and
 educate all youth about the truthful significant
 historical contributions by Blacks to society
 today. The current educational system fails to
 teach the truth about history specifically the
 original contributions to civilization, science and
 technology by Africans via Ethiopia, Egypt, the
 Black Pharaohs contributions by the building of
 the pyramids. The first great physician Imhotep
 was an African physician. The teaching of the
 accomplishments of Blacks both ancient and
 modern in the New York City public school
 system would improve the self-esteem to Blacks
 to achieve and strive to become the future Black
 or American Heroes.
We need to Train More Black
and Black Hispanic Physicians
– More minority
  health care
  providers are
  needed especially
  since they are more
  likely to serve in
  minority and
Must Support Health Pipeline
 *Support Reading Programs
 Encourage all students to carry a book and read 1-2
 hours a day.
 Stop the notion in the Black community that reading
 is acting white, this is a concept that is still prevalent
 from slavery in many black communities.
 Support Mentoring programs
 Support educational summer programs and
 afterschool programs
Improve Health Literacy and
 Break Language Barriers
 – More interpreters to overcome language
 – Grassroots community based health
   workers to help patient navigate and
   access the health care system
 – Provide understandable patient
   education programs and materials to
   increase patients knowledge of how to
   access care
 – For patients whom cannot read, we must
   communicate effectively to our patients
Educate individuals about
 Personal Responsibility
   Increase physical activity
      – Walking, running, athletics,
      – Expand physical education
         requirement in schools at least
   Health diet
      – Increase water intake,
         vegetables, fruit, lean chicken
         and fish
      – Avoid high caloric fats, red
         meats, starches, soda, juices
   Healthier behavior
      – Avoid premarital/unprotected
         sex, smoking, drinking,
         substance abuse

                 Reduce Stress
             Must Stop & Prevent
                Tobacco Use
   Most preventable cause of death in
    our society accounting for 30% of
    all cancer deaths
   Causes nearly 87% of all lung
   People who quit before the age of
    50 cut their risk of dying in the next
    15 years in half
   A Major Cause of Cardiovascular
   80% of smokers begin to smoke
    before the age of 18
     If crime is down 30% why is
           incarceration up?
   There is racial bias at every stage of the criminal justice system
    including policing, arrests, sentencing and parole.
   In Suffolk County Blacks make up 7% of the population but
    40% of the jail population.
   In Rensselaer County Blacks make up 5% of the population but
    35% of the jail population.
   We MUST STOP DISCRIMINATION, The statistics are not a
    result of more criminal behavior in the Black community
   We must Stop the State Commission of Corrections from
    mandating the construction of correctional facilities in NYS
   We must institute contract controls to monitor how contracts
    are distributed and their impacts on taxpayers
Prevent the Incarceration of Black
 Education
 Community Centers
 After school programs
 Provide comprehensive
  behavior intervention for
  those whom may be in need
 Re-educate and provide job
  training and transition
  programs to those
  incarcerated and to be
 Provide mental health to
  those in need
 Stop racial discrimination I
  policing and stop arrest
Bring Divert Court model from Dallas
 Texas to NY to reduce incarceration
  Established 10 years ago Divert Court has been
  shown to have a tremendous cost/benefit
  On average, for every $1 spent on upgrading drug
  treatment and diverting offenders from traditional
  incarceration, to drug treatment through DIVERT
  Court, $9.43 of costs can be saved by society over a
  40 month post-treatment period.
  Emphasis is place on rehab and treatment and avoiding

Alternative to Jail Construction
   Creating Pre-Arrest Programs, Citation programs to avoid initial
   Programs for the mentally ill
   Improve release procedures and the pretrial and sentenced
   Specialty courts, drug court, mental health court, domestic
    violence court
   Alternative punishment to incarceration including expanding
   All suggestions will save NYS taxpayer millions of dollars
  Youth Conflict resolution
    and Legal Education
Create violence reduction, conflict resolution, and
preventive law education protocols for junior high
school students and public: Rationale: This will help
reduce prevent incarceration. The state does not allow
religion to be taught in schools. Thus there is a void in
the teaching of morals and principles of right and
wrong. Children coming from poorer families often
have parents away from the home working 2 and 3
jobs to make ends meet and maybe deprived of this
nurturing. The educational system must participate in
educating students about the consequences of criminal
We must also have funding for research identifying the
most common zip codes with incarcerated minority
youth, and identifying the reasons for incarceration
and create programs to prevent this adverse outcome
in those specific zip codes.
    NYC “Take Care New York”
    Have a regular doctor
    Be tobacco free
    Keep your heart healthy (control weight, Cholesterol, BP)
    Know your HIV status
    Get help for depression
    Live free of dependence on alcohol and drugs
    Get checked for cancer
    Get the immunizations you need
    Make your home safe and healthy from lead
    Have a healthy baby, obtain prenatal care

    NYC Department of Health and Mental Hygiene
Empire State Medical Association
      Recommendations to
  address healthcare disparities
     Cultural Competency
Legislation must be enacted to ensure Mandatory
Cultural Competency for all Physicians and Healthcare
Workers in New York State. All licensed healthcare
workers in New York must be made aware of the
terminal effects of prejudice in healthcare on ethnic
minority groups in New York State. David Satcher M.D.
the former U.S. Surgeon General estimates there are
over 83,570 annual premature deaths due to prejudice
in healthcare. Dr. Nelson Adams the 111th President of
the National Medical Association states: "Cultural
competency education is urgently needed, racial
inequities in healthcare will never be scientifically
justified, politically excusable, and never morally
     Health Insurance Reform
Eliminate Health maintenance organizations: Rationale: Health
maintenance organizations are a middle man in medicine. They
deliver no health care and have the best interests of the their
investors, shareholders, and executive compensation. Recently
the CEO of United Healthcare Dr. McGuire earned 1.6 billion
dollars in stock options. Instead of this money being invested
for infrastructure in healthcare it is being used for personal
use. Legislation must be passed to make healthcare a basic
human right and not a privilege.
There are over 2 million New Yorkers without health insurance.
The concepts of referral use and capitation by HMO’s only
discourage the physician patient encounter delaying health care
decreasing access to health care.
This has led to many hospitals closing in New York and
physicians closing their offices. In New York hospitals lose
approximately $750 million dollars annually and the HMO’s
profit over 750 million dollars. Getting rid of HMO’s and
centralizing care to a few would reduce the amount of money
spent on administration and allow patients, and hospitals to
thrive. More patients would also be able to obtain insurance
with the expansion of the Medicaid, Child health plus program,
Health NY program and Medicare program to insure all New
Diversify the leadership at the NYS
      Department of Health

   Black employees at the Department of Health are sorely
    underrepresented, <2 %
   Black employees at the department of health are tracked into
    locations where the pathways to promotion have been
   NYS DOH must include health disparities in all efforts
    addressing healthcare for New Yorkers.
   Current NYS DOH organizational infrastructure encourages
    and perpetuates unequal promotion, unequal distribution of
    resources further exacerbating healthcare disparities.
NYS Dept of Health Call to Action

   Must expose and eliminate deeply embedded pathways, procedures
    and practices that foster unequal geography of institutional
   Increase the ability of Blacks and Latinos to build and maintain
    knowledge and leadership capital, maximize growth potential, and be
    promoted within the department of health.
   Bring the Office of Minority Health from the fringe to the core of the
    public health system
   Relocate the Office of Minority Health to the Office of the
    Commissioner of Health
   Increase funding to the NYS Office of Minority Health, recently its
    budget has been decreasing from >1 million dollars to $693,000.
   Articulate a clear vision and a comprehensive plan with performance
    measures towards eliminating health care disparities.
       NYS Governor: Issuing an
           Executive Order

   Issue an Executive Order to require that each state agency
    shall make eliminating inequities part of its mission by
    identifying and addressing as appropriate, disproportionately
    high and adverse human health and environmental effects of
    its programs, policies and activities on minority populations and
    low income populations in New York State.
   Encourage the Attorney General’s Office to challenge
    systematic inequities in the health care system including public
Consider Banning Alcohol and
 Tobacco Advertising in NY
 These companies advertise heavily in Black and
 Latino communities in NYC leading to increased
 disease and disparities in Southeast Queens,
 Central Brooklyn, South Bronx and Harlem.
 Banning these ads will help stop the
 glamorization of these destructive products.

 The smoking ban in public places has worked
 well to reduce the number of new smokers.
   Positive Public Health
Educational Ads on Radio and
 Create and enhance preventive public service
 Educational advertisements regarding diet,
 exercise, substance abuse, smoking, sexually
 transmitted diseases will help prevent premature
 death from cardiovascular disease, cancer,
 homicide, HIV .
 Educational announcements of reducing asthma
 by reducing air pollution and household mold.
 Advertisements via radio, television, billboard
 posters and press conferences are very effective
 toward educating the public about the latest
 health alerts, issues and action initiatives.
   Stop Medicaid Cuts to Private
 Physicians to allow greater access
for patients to have a medical home
Repeal the New York Medicaid cuts for healthcare for
those patients with dual Eligibility with Medicare:
These cut backs have reduced patient’s access to
private physicians in poorer and underserved
The cutbacks also discourages physicians from setting
up practices in poor communities since they will be
receiving less reimbursement than physicians whom
practice in wealthier communities.
Physicians that open up their primary practices,
(>50% time) in poorer underserved neighborhoods in
designated zip codes in central Brooklyn, Southeast
Queens, South Bronx, and Harlem, should also receive
special state and city income tax and property tax
breaks to offset student loans and lower income
received from serving these communities and receive
increased reimbursement.
            Tort Reform
Tort reform with caps on malpractice awards.
This will ensure more funds available for
healthcare instead of trial lawyers that on many
occasions file frivolous lawsuits costing
healthcare providers millions of dollars depleting
monies for healthcare.

Ob-Gyn Malpractice insurance in NY ranges from
$150,000 to $250,000.

7 counties in NYS do not
have an Ob-Gyn as a result of this.
                  Tort Statistics
   The average medical liability award has gone up 35% to
   The civil justice system frequently produces awards where
    there has been no negligence
   In many cases where there has been negligence the system
    often produces no payments to the plaintiff
   Physicians are now increasingly being forced to view their
    patients as potential plaintiffs rather then person in need of
   Over the past 10 years MLMIC has spent of $500 million to
    defense physicians and hospitals on whose behalf no payment
    was ever paid to the plaintiff that filed a claim.
                  Tort Statistics

   In NY 71% of Neurosurgeons have been sued
   In NY 67% of Ob-Gyns have been sued
   No other level of human activity is the source of such lawsuits
   Many hospitals have close their OB-Gyn divisions
                Tort Legislative

   Special health courts
   No-fault system for claims involving neurologically impaired
    infants and emergency department care.
   Most neurological conditions involve impairment prior to birth.
   Tightening of rules of whom can be an expert witness in a
    medical liability action.
   Disclosure of the identity of an expert witness in a medical
    liability action prior to trial.
   Expert witnesses must be practicing the same specialty as the
    physician whom against whom the lawsuit if filed.
   $250,000 cap on non-economic damage awards.
          Tort Reform Legislative
   State-funded subsidy and/or tax credit to defray the cost of
    medical liability insurance.
   Create a “clear and convincing” standard of proof in medical
    liability actions, a higher standard than the current
    “preponderance of the evidence standard”
   Impose a $10,000 fine on an attorney who brings frivolous
    action and enforce the penalty
   Immunity for Apology- 27 states have and “I’m sorry Law” to
    protect health care providers who express sympathy to a
    patient for an unanticipated outcome from having such a
    statement used against the health care provider in any
    subsequent litigation that may arise.
   50% discount on malpractice premium for those physicians that
    practice in zip codes affected by the highest healthcare
Contact Medical Schools to
invest in diversity as well as
Contact all local New York Medical Schools and
Hospitals to immediately enforce nondiscriminatory
laws by recruiting underrepresented Black and
Hispanic physicians, medical students and health
personnel: Currently New York City is 60% Black and
Hispanic. The number of Black and Hispanics in New
York Medical Schools are 5%. The leadership in both
medical schools and hospitals has failed to diversify
and support the medical staff to address current
healthcare disparities.
Reduce the cost of medical education.
    Blue/White collar
Job & Technology Training
In some areas of NY as much as 51% of Black
men in are unemployed.
Immediately develop job-training programs:
Unemployment leads to poverty, substance
abuse, and crime. Not only are the men affected
but also the women and children of the family.
Reduce the cost of Prescription
 Globally Drug companies make 50% of their
 profits off of the American consumer alone.
 Pharmaceutical cost reduction protocols such as
 those used in Canada and other countries will
 reduce the cost the medications particularly for
 patients whom are poor and may not be able to
 afford them to reduce health disparities.
 Legislation must be considered to reduce the
 mark up of medications.
 Parallel importation of drugs will stimulate free
 enterprise and reduce the costs of medications as
 is seen in Europe.
We are against Retail Health Clinics

   Patients need to see physicians in a “medical home” at their
    doctor’s office, not a drug store clinic that bombards them with
    unhealthy candy, chips, soda and food as you enter the drug
   Doctor don’t spend 8-15 years of their life training to work out
    of a retail drug store.
 All of the above recommendations should
   be targeting the zip codes in New York
    that are clearly known to have these
     disparities in health, education, and
     unemployment. Specifically Central
     Brooklyn, Uptown Manhattan, South
           Bronx, Southeast Queens.
        Areas most in need:
Harlem, So. Bronx, Central Brooklyn
 Failure to Address
Healthcare Disparities
     will lead to:
     Increased taxpayer costs for
     Increased waste of resources for
     Increased social service costs
     Decreased productivity
     Decreased national and global
      competitiveness of New York
      City and New York State
     Will you be part of the problem or
      part of the solution to address
      healthcare disparities in New

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