Yale Cancer Center researchers analyzed more than 30,000 health records and found that, prior to Medicaid expansion, black adults with advanced or metastatic cancer were 4.8 percentage points less likely than white adults to begin treatments within 30 days of being diagnosed. But in states where Medicaid was expanded, in 2014 or later, the percentage of black patients getting timely treatment rose from 43.5 percent to 49.6 percent.

There also was a small improvement in expansion states among white patients receiving timely treatment – from 48.3 percent to 50.3 percent – bringing the post-expansion difference between the two racial groups to less than one percentage point.

“Our results suggest that Medicaid expansion led to improved health equity,” said study author Amy Davidoff, a senior research scientist at Yale School of Public Health and in Yale Cancer Center’s Cancer Outcomes, Public Policy, and Effectiveness Research Center (COPPER).

Having access to insurance can significantly impact outcomes in cancer patients, she said.

“It’s huge,” she said. “It really starts out with access to screening; just having any insurance coverage is really important in access to screening. Having insurance really dramatically opens that door.”

Often, cancer is diagnosed only after a patient presents with symptoms to a primary care doctor, she added, and having insurance increases the likelihood patients have a primary physician they see regularly. Insurance also helps gain access to specialists, Davidoff said.

Yale School of Public Health Photo.

Amy Davidoff, researcher.

Davidoff and Dr. Cary Gross, director of COPPER, led the research in partnership with Flatiron Health, a New York City-based electronic health record company that provided the data, funded the study and was the impetus for the research. The company specializes in software and services for oncology providers.

Researchers examined 30,386 anonymous electronic health records dated from 2011 to 2019 from Flatiron Health’s database. The analysis looked at timely treatment, provided within 30 days of diagnosis, for eight advanced or metastatic cancer types.

While the study suggests that Medicaid expansion eliminated the racial disparity in timely cancer treatments, it doesn’t prove it, said Davidoff.

“I see this as contributing to our understanding of how the ACA might be affecting the process of cancer care, and how it might affect disparities in that care,” she said. The study was the first of its kind to take a “deep dive” into the process of cancer treatment and disparities therein, she added. It examined the disparity between white and black patients because those groups had the largest sample sizes in the data provided.

“I was actually surprised at how big the effect was,” Davidoff said of the results. “The fact that we saw this pretty huge effect was exciting but surprising.”

In 2010, Connecticut was the first state in the nation to expand Medicaid. The option, available under the ACA, allows states to extend coverage to anyone living in a household where the income is below 138 percent of the federal poverty level. The federal poverty level for a family of four this year is household income of $25,750.

Nationwide 35 other states and Washington, D.C. have expanded Medicaid under the ACA; 14 states have not.

While the patients in this study would need to be tracked over time to see what their outcomes ultimately are, the research is encouraging, said Patricia Baker, president and CEO of the Connecticut Health Foundation.

“It is not surprising that research found that coverage made a difference,” said Baker. “With coverage they were able to access care in a timely manner. This is what many of us hoped coverage would bring with it – not the cure-all for racial disparity, but to give greater opportunity for people to optimize their health.”

School work, sports commitments, family and social obligations: life as a teenager can be stressful, he says. If it weren’t for the health center, conveniently located where he spends most of his days, he would have a much harder time accessing counseling sessions that help him cope with anxiety.

Carl Jordan Castro Photo.

Emily Segal, clinical supervisor and social worker at Stamford High School’s health clinic, talks with a student who regularly visits her office.

“The health center helps me out academically, emotionally and physically,” he said, and he recommends it to friends. “They get nervous, kind of, but I try my best to get them to come in. They never regret it.”

Sanchez, 16, is among a growing number of black and Hispanic teens receiving mental health services at school-based health centers—services, data show, they’d be much less likely to get or stick with if they pursued them elsewhere in their communities.

“For many students, this is the primary place where they get their care,” said Jesse White-Fresé, executive director of the Connecticut Association of School Based Health Centers.

For the 2007-08 and 2008-09 school years, 1,130 black and Hispanic males in grades seven through 12 received mental health services, data collected from 75 state-funded health centers show. Those youths registered 15,386 visits over the two-year period, the association’s issue brief reports.

White-Fresé suspects the number of males served is higher than reported since the data includes only students whose parents agreed to disclose ethnicity during enrollment.

While students seek services for various reasons, research shows black and Hispanic students are more likely than their white peers to experience depression in particular.

In 2015, 36 percent of Hispanic high schools students and 27.3 percent of black students reported feeling so sad or hopeless every day for two or more weeks that they stopped doing some of their usual activities, according to the state Department of Public Health’s 2015 Connecticut Youth Risk Behavior Survey. By comparison, 22.6 percent of white students answered the same.

Against that backdrop, just 25.4 percent of all students said they receive the help they need when they feel sad, empty, hopeless, angry or anxious, the survey said.

Statewide there are more than 120 school-based health centers providing medical and mental health services to students, most of which have part of their operating expenses funded by the state.

Centers are often staffed with medical providers who can prescribe medication, and bill Medicaid, HUSKY A and HUSKY B for services. A school nurse can refer a student to a center, but a parent must sign a permission form for their child to receive care.

During the 2007-08 and 2008-09 school years, black and Hispanic students participated in an average of 13.6 therapy sessions, each session lasting 30 to 35 minutes. That same demographic typically stops seeing providers in their community after two or three sessions, according to the association.

Carl Jordan Castro Photo.

A student holds a stress ball while conversing with social worker Emily Segal.

“That is quite significant,” said Patricia Baker, president and CEO of the Connecticut Health Foundation, which funded the association’s study. “Schools are the most common setting in which kids can access mental health care.”

Various factors prevent youths from accessing care in their community, said White-Fresé. It often is difficult to get an appointment outside of school hours, for instance, and lack of transportation can be problematic.

“There are some real disparities that are happening but in this [school] setting those disparities are reduced,” she added.

If he couldn’t receive services in school, Sanchez says, it would be difficult to fit therapy sessions around school, sports and church obligations. He began accessing services in seventh grade at his middle school. At Stamford High School’s center, he has a standing weekly appointment with social worker Emily Segal and can often get a same-day appointment if an emergency arises.

“It makes life easier for me,” he said.

Segal has been working at the center, run by nonprofit Family Centers, for 17 years and sees a growing number of students seeking help for anxiety.

“There’s a lot of stress on these students,” she said. “It’s a tense, stressful time.”

Segal is a valuable resource “when you need someone to talk to,” said Berwens Desgazon, 15, a sophomore who receives mental health services. “If you have an emergency, you can just walk a couple of steps to get help.”

Desgazon has had weekly one-on-one sessions with Segal since last year. He says the center is a place he feels comfortable and safe discussing what’s happening in his life.

At Windham High School, which also has a health center, wellness center therapist Carolyn Franzen says being in the school helps her bond with students.

“I’m part of their world,” she said. “They’re going to see me every day; they’re going to see me in the halls. I know their friends. It’s very different than leaving and driving to somebody’s office to get help.”

Windham High School’s student population is 70 percent Hispanic, she said, and roughly 90 percent of the school’s total population is enrolled in the center, which is affiliated with Windham Hospital.

In addition to the one-on-one counseling available at many centers, some offer group therapy as part of the Cognitive Behavioral Intervention for Trauma in Schools program. That national initiative launched in Connecticut in 2014 and most students who participate are black or Hispanic, according to Jason Lang, vice president for mental health initiatives at the Child Health and Development Institute, which trains mental health service providers.

About 50 Connecticut schools use the program, some of which offer the service at school-based health centers. Geared toward students who have experienced trauma, the program includes 10 group sessions. Statewide, 70 percent of participants are Hispanic, 20 percent are black and less than 10 percent are white, Lang said. Roughly half are males, he added.

“The group setting has benefits because children hear from their peers who have experienced similar things,” he said. “One of the challenges with trauma is that, because people tend not to talk about these things, people tend to think they’re alone and they’re the only ones who have experienced it.”

Leaving mental health issues untreated can have serious consequences, including truancy, involvement in the juvenile justice system, school suspensions, and aggressive incidents, a study by the Center for Children’s Advocacy at the UConn School of Law found.

Funding uncertainty nearly jeopardized the strides centers have made, Baker said.

Carl Jordan Castro Photo.

The entrance to Stamford High School’s health clinic.

Gov. Dannel P. Malloy’s initial proposal appropriated $9.97 million to school-based health centers in the 2019 fiscal year, nearly a 10 percent reduction from what previously had been budgeted for 2019 and at least the third consecutive year in which state funding has been reduced.

The budget that was passed May 9 allocates $10.7 million to the centers for 2019. While that is a decrease from the $11 million originally slated for the centers in the Democratic budget proposal, it was not quite as severe as the funding cut in the governor’s proposed budget, according to White-Fresé.

“They’ve been experiencing cuts—a little here, a little there,” Baker said. “Connecticut’s done a great job about school-based health centers, but we’re now at the point where tough [budget] decisions are being made.”

They contacted emergency departments at Yale New Haven Hospital and its Saint Raphael campus and enrolled 100 patients in their study in 2013. Those selected had visited emergency rooms four to 18 times in the past year for chest pain, abdominal pain or chronic migraines, among other ailments.

Derek Torrellas Photo.

Milagrosa Seguinot, a CHW, entertains Madeley, 2, while Dania Lizeth Robles Navarro fills out health care forms in their Bridgeport home.

The navigators at Project Access coordinated health care for the patients. They scheduled appointments with primary care physicians, provided reminders, accompanied patients to physician visits and followed up to ensure compliance with the prescribed treatment.

The preliminary results were eye-opening: “We saw an average cost reduction of $153 per member per month,” said Dr. Roberta Capp, assistant professor, Department of Emergency Medicine at the University of Colorado Denver, and lead investigator of the study.

Over the intervening six-month period, the use of emergency rooms dropped 22 percent among patients in the study, and the number of times they were treated and admitted to hospitals dropped 48 percent, compared with the control group of 51 patients, who received no help from navigators.

Patient navigators, also called community health workers or care coordinators, are employed by nonprofits, hospitals, clinics and federally qualified health centers. Their goal is to improve access to care and health outcomes and reduce cost.

Yet, in part because of funding, they are sorely underutilized.

“My organization is entirely grant-funded, and grant money is thin-spread,” said Darcey Cobbs-Lomax, executive director, Project Access. “On top of that, we don’t currently have a state budget. So, I no longer have my $200,000 state contract, which was paying for our patient navigators’ salary.”

Project Access was able to retain its navigators, thanks to its rainy-day fund. “But I know organizations that on July 1 had to let go of [their community health workers].”

Paying For Patient Navigators

Connecticut is like most states that pay community health workers through grants. Private insurance and Medicaid will not cover the cost of their work in Connecticut. But in some states, such as Minnesota and Pennsylvania, Medicaid covers community health workers’ pay.  “As a funder, we found that as soon as our grant funding ended, so did the employment of the community health worker,” said Patricia Baker, CEO of Connecticut Health Foundation Inc.

Consequently, the foundation asked the University of Massachusetts Medical School’s Center for Health Law and Economics to design four models based on successful programs nationally that use community health workers and would achieve a positive return on investment if implemented in Connecticut.

The study, published in this year, modeled four potential programs and their outcomes over three years:

• Diabetes control among 158 Latinos in Hartford – savings of $435,000;

• Asthma control among 96 children in New Haven – savings of $427,000;

• Reducing ED visits among 74 elderly patients with chronic conditions in New London County, savings of $944,000;

• Preventing cardiovascular disease complications in 148 adults in Windham County, savings of $388,000.

The current fee-for-service model, where payment is made to providers for each service offered – whether a test or a doctor visit – is another barrier to hiring and retaining community health workers, said Cobbs-Lomax.

Thirty-four states, including Connecticut, are working with the Centers for Medicare & Medicaid Services to lower health care costs and improve outcomes. At present, the State Innovation Model (SIM) is working on payment reform, but “there’s not really a way to fit CWHs in,” said Cobbs-Lomax.

This year, the legislature approved a bill to study the feasibility of creating a certification program for community health workers. The bill, signed by the governor, took effect Oct. 1.

“Most doctors’ offices don’t have the time and the staffing for care-coordination, which is critical in chronic disease management,” said Dr. Veena Vani, a Glastonbury-based physician. “That’s where care coordinators can make a big impact by educating patients and ensuring compliance.”

“We are hopeful for a day where health providers, hospital systems and payers align their work in ways that incorporate CHWs into the health care team to lead to better outcomes,” said Tekisha Dwan Everette, executive director, Health Equity Solutions Inc., Hartford.

Sujata Srinivasan Photo.

Jova Perez, a mother of two from New Haven, has a consultation with navigator Juan Carmona, who is guiding her through her breast cancer treatment and follow-up care.

A community health worker helped Jova Perez, a mother of two from New Haven, who was diagnosed with breast cancer at a community health clinic last year. Perez, who is uninsured and does not speak English, was referred to Project Access, where navigator Juan Carmona put her under the care of volunteer oncologists, surgeons and radiologists.

“There are language barriers, understanding the treatment and access to doctors,” said Carmona. “It’s a lot for a patient to handle.”

Said Perez: “I don’t know what I would have done without all of them.”

Interventions can lower health care costs, especially for people on Medicaid, experts say.

In 2016, the state spent $245 million on ED visits alone, up from $227.8 million in 2014 – a 7.6 percent increase, according to the state Department of Social Services. ED costs per Medicaid member per month rose 2.97 percent during the period, driven by an 8 percent increase in cost per ED visit. Part of that is also a steady increase in enrollment, to 780,399 as of July 1, 2017, for Husky Health.

Cultural Shift

Providers note that it’s not enough to treat patients medically unless other problems are fixed.

“Fifty-five percent of our patients live at or below the poverty line,” said Lauren Kelley, director, Research and Evaluation at Project Access. “Many have low levels of formal education and health literacy, and experience food insecurity and homelessness.”

At the Southwestern Area Health Education Center Inc., in Shelton, CHWs make home visits to get Bridgeport children, age 0-2 vaccinated.

As a result, Milagrosa Seguinot, CHW project coordinator, said, vaccination rates rose to 83 percent in 2015, organization’s 2015 data show, up from 63 percent in 2005. Also, only 53 percent of children had a checkup with a primary care doctor in 2005. That number climbed to 94 percent in 2015.

“We have knowledge of how the community lives, and we know how to connect with them,” said Seguinot.

An analysis of data compiled by the Institute for Health Metrics and Evaluation at the University of Washington, published in JAMA, also shows wide disparities between Connecticut counties in death rates from certain cancers and other illnesses. Windham County had the highest mortality rates for seven of 10 cancers identified in the study as having the highest disease burden or responsiveness to screening and treatment, including pancreatic, uterine and lung cancer.

Tolland County, meanwhile, had the lowest death rates for five cancers, including breast cancer, while Fairfield County was lowest for four.

Similarly, deaths from chronic respiratory diseases in Windham County were nearly double the rate in Fairfield County – 63.13 per 100,000, compared to 34.15. Mortality rates for neurological disorders ranged from a low of 75.07 in Tolland County, to a high of 116.89 in Middlesex County. The rates are from 2014.

Experts say the disparities likely stem from a combination of factors, including access to screening and early detection, lifestyle risks, and the availability of treatment options. Windham County has the lowest median household income in the state, while Fairfield has the highest, followed by Tolland, according to 2014 census data.

“It’s quite a complex interaction” that leads to disparities based on socioeconomic factors, said Lou Gonsalves, an epidemiology with the state Department of Public Health (DPH)’s tumor registry. “Things like access to early detection, lifestyle factors such as smoking and obesity, the willingness to interact with medical services” are all elements.

She said DPH is working closely with the Connecticut Cancer Partnership to identify and address disparities “from diagnosis to end-of-life care.”

Patricia Baker, president and CEO of the Connecticut Health Foundation, said that while the state should be pleased with the improvements in health outcomes, “what isn’t surprising is the disparities that exist geographically and racially and ethnically.

“Windham County is often forgotten, yet has some of the most glaring disparities,” she said. “While Connecticut is expanding access, the story often heard in Windham County is the challenge in attracting providers, and income is a large determinant of health.”

Racial and ethnic disparities in mortality remain pronounced in Connecticut, as they do nationally. A 2016 DPH state health profile compiled as part of the Connecticut State Innovation Model (SIM) report shows higher death rates among African-Americans from breast, prostate and colorectal cancer, and higher mortality among Hispanic women for cervical cancer.

Connecticut has seen a significant drop in female deaths from breast cancer since 1980, when its mortality rate was higher than the national average – 41.85 deaths per 100,000, compared to 37.41 nationally. In 2014, Connecticut’s rate fell to 23.54 — below the national average of 25.88. Death rates from colon and rectal cancer also fell from higher than the national rate to below average.

In fact, in all but four of 27 categories of cancer, the state has lower mortality rates than the U.S. as a whole. For all cancers (or neoplasms) combined, Connecticut’s death rate dropped 28 percent from 1980 to 2014 – more than the national drop of 20 percent. The state is now at 179.49 deaths per 100,000 – lower than U.S. rate of 192.04.

The exceptions are higher-than-average rates of stomach cancer, pancreatic cancer, uterine cancer and bladder cancer, the 2014 data show.

Gonsalves said those four cancers are harder to detect early, and so are more likely to be found in later stages.

For non-cancer deaths, Connecticut fares well in the rate of cardiovascular diseases, with the mortality rate dropping by more than 50 percent since 1980 and now below the national average. The death rate for neonatal disorders also has fallen sharply, both in Connecticut and nationally, although the state’s rate remains slightly higher than the national average (3.32).

But in other areas, the study shows, Connecticut has higher mortality than the U.S. as a whole. Deaths from mental health and substance use disorders claimed 14.2 of 100,000 lives in 2014, triple the rate in 1980.

Last month, the state medical examiner’s office reported 917 drug overdose deaths in 2016 – a 25 percent increase over 2015. The synthetic opioid fentanyl accounted for the biggest increase.

The study shows that Connecticut’s death rate from chronic respiratory diseases also has climbed, as it has nationally — from 34.86 in 1980 to 43.87 in 2014, a 26 percent increase – although it remains below the national average.

Connecticut’s death rate from unintentional or accidental injuries declined slightly since 1980, but is now higher than the national average. For diabetes, urogenital, blood and endocrine diseases, Connecticut’s death rate has risen 15 percent since 1980, but remains below the national average.

Disparities between counties are stark for some cancers and other diseases. Death rates for cervical cancer, for example, ranged from 1.04 per 100,000 in Tolland, to 1.92 in New Haven. For lung, tracheal and bronchus cancers, Windham County’s rate was 53 percent higher than Fairfield County’s.

Breast cancer mortality rates among women ranged from 20.42 in Tolland County to 24.63 in Windham County and 24.56 in New Haven County.

Mental health and substance use disorders claimed 16.45 lives per 100,000 in Hartford, compared to a low of 9.64 deaths in Tolland. Hartford also had the highest rate of deaths from neonatal disorders – 4.33, more than double the lowest rate (2.0) in Litchfield County.

A State Health Assessment from 2014 shows that towns in the eastern part of Connecticut, including Windham County, had higher rates of all-cause premature mortality. It notes that access to health care, including mental health, is a major issue facing the state’s rural population.

Data on life expectancy, dating from 2013, show a two- to three-year longevity gap among counties, with women in Fairfield County living longest (to 84.14 years, on average), and women in Windham County shortest (81.84). Among men, Fairfield County residents had the longest average lifespan (79.99 years), while those in Windham had the shortest (76.58 years).

Nationally in 2014, the lowest all-cancer death rate was 70.7 deaths per 100,000 population for Summit County, Colorado; the highest was 503.1 in Union County, Florida.

The study shows that the pattern of change across counties varied by cancer type. For some cancers—such as colon and rectum, larynx, stomach, breast, cervical, prostate and testicular — mortality rates declined in nearly all counties; for others, including liver cancer and mesothelioma, they increased in nearly all counties. For the remaining cancers, rates increased in some counties and declined in others.

“My wife gets sick and I don’t have a clue how to navigate,” Greg Butler said. “This stuff is enormously complicated. What does your insurance cover? Or not? How do you appeal this stuff? How do you find the right specialist?”

In July 2015, the Connecticut Health Foundation, where Butler serves as board chair, funded a study that showed that community health workers, or CHWs, could help simplify certain parts of the health care system, and they serve a much-needed role that highly trained medical professionals, such as doctors, can find challenging.

“They know that Mrs. McGillicuddy is on insulin, and they can make sure she’s taken her insulin today,” said Greg Butler. “They know that Mrs. Hernandez’s kids have asthma, and they can make sure she’s vacuuming under the couch.”

Community health workers connect patients with proper medical care.

A doctor can talk to a patient about the importance of proper diet, but a CHW is in the community already, and knows the patients, the culture, and the language. CHWs are health care workers who deliver more than basic medical care. They can connect patients with the proper medical care as needed, and they can influence a patient’s behavior for long-term benefits.

“They must have training but we cannot over-professionalize the CHW,” said Patricia Baker, Connecticut Health Foundation president and CEO. “They are the bridge between community and clinical care. They should be used in a targeted manner such as supporting complex patients.”

CHWs already have had some credible effects on underserved communities throughout the country.

Connecticut has had CHWs for a while, Baker said. They’ve been called navigators, patient advocates, and outreach workers. One Massachusetts study said CHWs go by as many as 50 different titles. The foundation has long supported CHW programs, but Baker said they’ve shifted their attention to more systemic investments. Otherwise, programs end when grant money runs out, Baker said.

The non-profit Project Access in New Haven uses CHWs to great success. Founded in 2009 by local physicians to overcome inequality of health care, 73 percent of Project Access patients are Hispanic or Latino; 63 percent are female; and 78 percent have a high school education or less. All the agency’s patients are poor, and all are uninsured. Community health workers are critical to the success of the program, Baker says.

Baker says the recent election of Donald J. Trump, who has promised to dismantle some or all of Obamacare, shouldn’t affect CHW programs.

“Even states that are considered red,” such as Texas, “are utilizing CHWs in their Medicaid Managed Care plans so this work is happening,” Baker said. Research shows that the workers curb health care costs, and deliver better health outcomes.

A 2012 American Cancer Society study found that community health workers generate lifetime benefits of $12,348 per person served, or $851,410 for every CHW who serves at least 69 individuals a year. The benefits come in the form of more taxes paid by people who live longer, as well as savings from a reduction in the use of emergency or urgent care facilities. Every $1 invested in a CHW yields $2.33 in return, according to the study. A similar study in Denver yielded the same results.

In Baltimore, a CHW intervention program saved an average of $2,245 per patient, for a total savings of $262,080 for 117 patients. The study said the intervention program also gave the patients a better quality of life.

The program works, and members of a state community health worker advisory committee within the Office of the Healthcare Advocate are studying what should be their training, promotion, and certification process. As of a year ago, 15 states had established or were moving toward establishing their own certification process. In neighboring Massachusetts, training includes 80 hours in the class, though for now, credit is given for work already completed. That pathway will be eliminated within the next few years.

In short, this is an approach the works. It saves money. It gives patients a shot at better outcomes. As we feel our way through the next few uncertain years, we could use a community-based program like this.

Susan Campbell is a distinguished lecturer at the University of New Haven. She can be reached at slcampbell417@gmail.com.

In fact, nearly one out of every two African American women living in Connecticut suffers from hypertension, a life-threatening condition that can lead to heart attack, stroke and kidney disease, research shows.

The rising trend in hypertension coincides with increasing adult obesity rates in Connecticut and the nation, as stepped up efforts focusing on wellness — from Michelle Obama’s national physical activity campaign “Let’s Move!” to serving healthier meals at local public schools — look to stem the tide in future generations. The state findings on hypertension mirror national statistics showing black women with the highest rates.

In Connecticut, health experts pointed to a mix of genetic, socioeconomic, and cultural factors as contributing to hypertension among black women. Long-term solutions, they said, call for intensifying outreach, screening and education efforts that are culturally sensitive to the unique challenges African American women face when it comes to their health.

Researchers at IHME collected data in 2001 and 2009 for hypertension.

Among the findings:

• More than 50 percent of the black women living in six of the state’s eight counties in 2009 – Litchfield, Middlesex, New Haven, New London, Tolland and Windham – had hypertension. The other two counties – Fairfield and Hartford – were close behind at about 48 percent.

• The highest rates in 2009 were in Windham County, where 54.6 percent of black women had hypertension, compared to 38.9 percent for whites and 42.7 percent for Hispanics. Black women in Fairfield County had the lowest rate (48.3 percent), but still significantly higher than their white (33.5 percent) and Hispanic (37.1 percent) neighbors.

• Hypertension rates among all African Americans, women and men, surpassed those of whites and Hispanics statewide. But black women were hardest hit, with rates higher than those for black men. In Middlesex County, which had the largest gap between the sexes, 51.9 percent of black women had high blood pressure, compared to 45.5 percent of black men in 2009.

• As hypertension increased among all women in Connecticut, so did the percentage with obesity, considered a major risk factor for high blood pressure. The highest increase was in Windham County, where 36.6 percent of women were obese in 2011, up from 27.3 percent in 2001.

“Hypertension is a silent killer,” said Dr. Edward Schuster, a cardiologist and director of the Tully Health and Fitness Institute at Stamford Hospital. “It’s more prevalent among African Americans, hits them earlier in life and, what’s worse, causes more heart attacks, strokes and kidney disease.” Commonly known as high blood pressure, hypertension occurs when blood pressure remains abnormally high.

Dr. Anita Kelsey, director of the Women’s Heart Program at St. Francis Hospital and Medical Center in Hartford, said physicians often fail to recognize or treat women with hypertension and cardiac issues, even though heart disease is the nation’s leading case of death for women. The program offers free cardiovascular risk assessments and education, with a focus on reaching women with no or limited health insurance.

“Studies show women are not treated as aggressively as men for cardiovascular risk factors by their primary care physicians across the board regardless of their health insurance,” said Kelsey. “As a practicing cardiologist, I’ve seen many women with medical records that indicate they’ve had high blood pressure for a decade. But no one told them it needs to be treated.”

The risk for hypertension can begin early in life, especially for the poor.

“People in lower social economic classes who have poor maternal nutrition when they are pregnant tend to have lower birth weight babies with stunted kidneys at birth that can lead to hypertension as you get older,” said Schuster. In Connecticut, 16 percent of the babies born to black women in 2010 had low birth weights, according to the state Department of Public Health.

Although genetic variations put African Americans at greater risk for hypertension, hereditary accounts for only about 20 percent, said Schuster. He points to studies showing that 14 percent of black women in Africa have hypertension, compared to 26 percent in the Caribbean and 33 percent in the United States. “This shows that some of the hypertension is genetics,” he said, “but a lot of it is caused by environmental factors.”

The stress associated with life as an African American – whether it’s struggling to pay bills, worrying about children in unsafe neighborhoods, or managing the subtleties of prejudice – can also take a toll on women’s health, according to state and national health experts.

“Many African American women are prioritizing children and family over their own health,” said Patricia Baker, president and chief executive office of the Connecticut Health Foundation, a non-profit organization working to reduce health disparities among people of color.

“We cannot deny that stress as a result of racism and discrimination is real. This is true not just for poor black women, but for middle class black women, as well,” she said.

Take the Rev. Nancy Kingwood-Small, for example. She’s deputy director of HIV Services at the Greater Bridgeport Area Prevention Program and an associate minister at the Mount Aery Baptist Church. She holds several degrees including a master’s in human services. Now she’s a student at Hartford Seminary pursuing a master’s in theology and ethics.

“Yet before I open my mouth, people see an overweight black woman. They have already categorized me because of who I am and not for what I can do or what I know,” said Kingwood-Small, who was diagnosed with hypertension seven years ago. “Often time, people think there is no more racism or discrimination. But it’s there. It’s alive and it’s doing well.”

Obesity and risk factors from poor diets, physical inactivity, and smoking contribute to the rise in hypertension.  “Obesity explains a lot of the hypertension,” said Schuster. Nationwide, four out of five African American women are overweight or obese, reports the US Office of Minority Health.

“I grew up eating macaroni and cheese, fried chicken and collard greens,” said Kingwood-Small. “It’s hard to change.”  She recalled her family’s reaction upon serving a healthier version of collard greens that substituted smoked turkey for ham hocks and neck bones: “This doesn’t taste like grandma’s!”

Fortunately, women can take steps early on to reduce their risk for hypertension through assessment, exercise and nutrition, said Kelsey, who works with a registered nurse, nutritionist and exercise physiologist at the Women’s Heart Program. More than 8,000 women have received risk assessments, education and follow-up support at St. Francis Hospital and community sites since the program began in 2006, leading to an overall reduction of 5 millimeters of mercury for systolic blood pressure.

“That may not sound like a large number, until you consider that a drop of 2 millimeters in mercury in systolic blood pressure across the nation, on average, would save 70,000 lives in one year,” she said.

Understanding cultural nuances is critical, said Kelsey. For example, speaking with African American women about losing weight poses challenges in a culture that doesn’t always celebrate thin women. Even using terms such as “body mass index” can alienate some women. These cultural subtleties underscore the “importance of having open conversations with women about why they can’t modify their lifestyles and what barriers need to be addressed to help them reduce their risk factors,” said Kelsey.

For Kingwood-Small, the “toughest part of managing this disease is my lifestyle. I am a workaholic.  My schedule is crazy busy at work and church, so I tend to pick up (unhealthy) food along the way.”

But “cultural factors” pose obstacles, too. “In the African American community, we eat for every occasion, whether it’s the birth of a baby, the death of a loved one, a wedding, or just family night,” she said. “There’s always a lot of food!” Being part of a community that dismisses hypertension doesn’t help. “You often hear black women say ‘Oh, my blood pressure is always a bit high’ as if it were nothing to worry about,” she said.

The 52-year-old decided to take action when she learned about hypertension’s deadly consequences. “I want to make sure I’m here for my eight grandchildren,” said Kingwood-Small, who believes education can empower black women to make lifestyle changes that benefit everyone.

“If you can change the mindset of the mother, you can change the mindset of the entire family.”

But with one in every four Hispanics lacking coverage, Serrano, a program director at Junta for Progressive Action in New Haven, is up for the challenge. Connecticut’s Hispanics represent the fastest-growing, youngest and poorest segment of the state’s population.

Kathleen Schassler Photo

Access Health CT event in New Haven.

Estimates of Connecticut’s uninsured vary. Approximately 344,000 people lack health insurance in Connecticut and 65 percent of the state’s uninsured are minorities, according to data being used by Access Health. Estimates released by the U.S. Census Bureau in September, however, put the uninsured at 284,000.

Between 100,000 to 130,000 state residents are expected to gain coverage in 2014 through federal health care reform initiatives. Access Health reported that about 7,000 state residents have expressed interest in the program thus far.

Yet getting Hispanics to enroll for coverage poses many challenges, said experts, who cited language and cultural barriers, a lack a familiarity with commercial insurance, fear surrounding immigration issues, and an inability to navigate a complex health care system as some of the obstacles they expect Spanish-speaking residents to encounter. Some advocates also worry the $6,000 grants awarded to assister organizations won’t be sufficient to sustain Hispanic outreach during the six-month enrollment period.

Junta for Progressive Action is among the estimated 300 “in-person assister” organizations poised to help Hispanics and others access new coverage through the Affordable Care Act. The assisters are working with six regional “navigator” organizations that will coordinate efforts and offer technical, cultural and linguistic support.

“Lots of people come to our doors asking about health insurance because health care is so expensive. Now we’ll be able to of offer them some real alternatives,” said Serrano. Junta is one of the scores of community agencies statewide that serves as a lifeline to Spanish-speaking residents.

“The widespread lack of health coverage is the most urgent health care problem facing Latinos today. It is a major contributing factor to poor health outcomes and premature death,” said Maritza Bond, executive director of Eastern Area Health Education Center, the navigator for New London County and 16 towns in Middlesex County. “Having health insurance will have a profound impact on quality of life for Latinos.”

The Affordable Care Act requires most Americans who can afford coverage to buy insurance or pay a tax. Access Health begins selling policies to consumers on Oct. 1, with coverage effective Jan. 1, 2014. Residents with moderate and low incomes are eligible for tax credits and subsidies to offset the costs. In addition, some individuals will be eligible for Medicaid for the first time under newly expanded eligibility guidelines.

“The big challenge will be reaching low income families as well as the working poor. Many people don’t realize they may qualify for Medicaid or can purchase subsidized coverage at Access Health. There’s a lot of education that needs to be done,” said Leticia Marulanda, director of programs at the Hispanic Health Council in Hartford. The Council is the navigator for Hartford County and four towns in Middlesex County and is serving as a statewide advisor to Access Health.

Efforts by Access Health to reach Hispanics include hosting a series of “Spanish friendly” Healthy Chats across the state, producing a television series called Mercado De Salud with Univision, and attending community events such as the Puerto Rican Parade. At least a third of the 300 in-person assisters selected by Access Health speak Spanish. Consumers can also view a Spanish version of the Access Health website. Assisters and navigators also received training on cultural competency.

“This is an important opportunity for those who are most disenfranchised,” said Patricia Baker, president and chief executive officer of the Connecticut Health Foundation, which awarded Access Health a $125,000 grant to support grass-roots education and enrollment, with a focus on increasing coverage in communities of color.

“If we don’t target our efforts, we are going to have the same uninsured numbers again,” said Baker. “We need a culturally and linguistically competent and sensitive approach to ensure that Latinos get their fair share. Having trusted people who understand their culture and language will be critically important.”

Dispelling myths about the law and increasing awareness about the benefits have been a top priority among outreach workers so far.  “We need to calm the chatter that’s out there,” said Emilia Skene, an in-person assister recruitment coordinator with Access Health. “There’s a misperception that the rules are punitive. We want to focus on the real benefits that the Affordable Care Act is going to bring to these communities.”

Yet with close to 28 percent of Connecticut’s Hispanics living in poverty, some community advocates fear health insurance will remain financially out of reach for many even with tax credits and subsidies.

“I see affordability as a major obstacle,” said Joan Cruz, director of special projects for the Hispanic Health Council. “It’s hard for people who don’t have a lot of extra money to spend hundreds of dollars on health insurance. There may be months when a family has to decide whether to pay the light bill or health insurance.”

Kathleen Schassler Photo

Among the hardest hit are individuals who fall between the cracks – they earn too much to qualify for Medicaid, but not enough to receive tax credits and subsidies to shop at Access Health. “What are we going to do with the population that falls in this bracket?” said Cruz. “They still need health care and they still face a penalty if they don’t have coverage. But we don’t have the funding to assist them in any way.”

Some Hispanic families may think twice about exploring the new coverage options because they don’t want to discuss immigration matters, said Yanil Terón, executive director of Center for Latino Progress in Hartford. “They’re concerned about coming forward,” she said. Undocumented immigrants cannot reap the law’s benefits, but their U.S.-born children can apply for HUSKY, the state’s subsidized health program.

Consumers must provide information about citizenship status, income and other matters to determine eligibility for Medicaid or subsidized private coverage with Access Health, but conversations remain confidential. “We want to create a safe environment for families who have people who are eligible for coverage but don’t want to jeopardize an undocumented individual,” said Skene from Access Health.

“There is no punitive immigration follow-up. That is 100 percent not part of the enrollment process,” added Jason Madrak, chief marketing officer for Access Health.

Money isn’t the only factor that may keep some Hispanics from buying coverage and accessing care.

“We need to change the way that Hispanics think about health care,” said Skene. “We want to show how accessing preventive care on a regular basis and establishing a long-term relationship with a physician can lead to a healthier lifestyle and a healthier community.”

“It’s true,” said Cruz, of the tendency by Hispanics to exhaust home remedies and over-the-counter medications before seeking medical care. “We were raised to try to solve these problems on our own. The last thing we want to do is go to the doctor.”

Marulanda worries about connecting Hispanics with services and providers once they have insurance. Given the shortage of primary care physicians, does Connecticut have enough doctors who understand the language and culture to care for the new influx of Hispanic patients? Will Hispanics access health care even if they have coverage?

“These are things we just don’t know yet,” said Marulanda.

Future funding to reach Hispanics is another unknown. According to the National Council for La Raza, outreach efforts will unlikely meet the needs of Hispanics without increased funding to community organizations. A NCLR survey found Hispanic health centers and agencies lacked the resources to carry out the complex enrollment process.

Connecticut’s Hispanic agencies also deserve a larger share of the available outreach funds, said Terón, who questioned Access Health’s “cookie cutter” approach to distribute $6,000 grants to every assister with the goal of enrolling at least 100 people, regardless of the population they serve. “The reality is that it’s significantly more time consuming and complicated to reach the Latino community,” said Terón.

Kate Gervais, manager of navigator and assister programs at Access Health, said distributing the same dollar amount to each assister was the most efficient way to tackle the “huge and complicated task” of funding hundreds of organizations. The number of assisters assigned to each region is based on data on the number of uninsured residents in every zip code. Navigator organizations will receive $30,000 to $50,000 grants, she said.

While many questions persist, for now, all eyes are on the opening of Access Health.

“Everybody was excited and ready to go live. The room was full of energy,” said Milagrosa Seguinot, of a recent meeting between the assister organizations and Southwestern Area Health Education Center, the navigator for Fairfield County. A Puerto Rican native and Bridgeport resident for 29 years, Seguinot is leading the regional effort.

“I feel very positive about this project,” she said. “We are making history.”

For information on the state’s insurance marketplace go here.

For information on the Affordable Care Act go to C-HIT’s health reform watch.