Maryland’s successful Health Enterprise Zones previously led by Congressman Brown considered for national adoption.

When Congressman Anthony Brown was Lt. Governor of Maryland, he implemented a new model for reducing health disparities: the creation of Health Enterprise Zones. The scheme aimed to tackle the problem of “healthcare deserts” through grants, incentives and tax credits, so increasing primary care and dental provision in some of Maryland’s underserved communities. In this podcast Rep. Brown discusses how the zones were conceived, why they succeeded, and explores why this matters even more in the age of COVID-19. Rep. Brown now aims to bring about national funding and adoption of the program through a new bill before congress. “This is not a partisan issue,” he says. “There are disparities that exist, often along racial and ethnic lines, often along geographic lines, and the bottom line is whether you are Republican or Democrat, you should want to ensure that every American has access to quality, affordable care and has an opportunity to live a healthy and meaningful life, which means a more productive life both at home and in the workplace”. Featuring Representative Anthony Brown, Maryland’s Fourth Congressional District, and Dr. Mary O’Connor, Chair of Movement is Life and Professor of Orthopedics and Rehabilitation at Yale School of Medicine.

Episode Transcription

Episode 66: Maryland’s successful Health Enterprise Zones previously led by Congressman Brown considered for national adoption.

When Congressman Anthony Brown was Lt. Governor of Maryland, he implemented a new model for reducing health disparities: the creation of Health Enterprise Zones. The scheme aimed to tackle the problem of “healthcare deserts” through grants, incentives and tax credits, so increasing primary care and dental provision in some of Maryland’s underserved communities. In this podcast Rep. Brown discusses how the zones were conceived, why they succeeded, and explores why this matters even more in the age of COVID-19. Rep. Brown now aims to bring about national funding and adoption of the program through a new bill before congress. “This is not a partisan issue,” he says. “There are disparities that exist, often along racial and ethnic lines, often along geographic lines, and the bottom line is whether you are Republican or Democrat, you should want to ensure that every American has access to quality, affordable care and has an opportunity to live a healthy and meaningful life, which means a more productive life both at home and in the workplace”. Featuring Representative Anthony Brown, Maryland’s Fourth Congressional District, and Dr. Mary O’Connor, Chair of Movement is Life and Professor of Orthopedics and Rehabilitation at Yale School of Medicine. Posted on September 30, 2020.

Dr. O’Connor: Welcome to the Movement is Life Health Disparities Podcast. We are pleased and honored to be joined today by Congressman Anthony Brown, who represents the Fourth Congressional District in the great state of Maryland. Congressman, first, let me just introduce myself. I’m Mary O’Connor. I chair a multi-stakeholder coalition called Movement is Life. We were founded 11 years ago, and I’ve been honored to lead the group and our focus has been on eliminating musculoskeletal health disparities, and we see the need for movement. That’s why we are called Movement is Life to combat joint disease, which combats obesity, because when your knees hurt and hips hurt and you don’t move, you gain weight, then you get arthritis and you get diabetes, hypertension, heart disease, depression. You get to be the kind of patient who walks into my office, I’m an orthopedic surgeon, who is often female, an individual of color with horrible arthritis, disabled, and who is a very poor surgical candidate because they’re obese, they have diabetes, heart disease. So, we need to get upstream of this whole problem and address how we get populations healthier. So, our mission is one of health equity. We can improve health equity if we improve a patient’s ability to move.

Anthony: Dr. O’Connor, it’s great to be on with you. It’s an important topic, an important set of issues I’ve been working on with my team, whether as Lieutenant Governor, now as a member of the House Representative. So, it’s exciting to be on today to be able to talk to you about these issues.

Dr. O’Connor: First, I think it would be interesting to our audience to cover a little bit of your background. So you grew up in Huntington, New York and your father was a family physician. Did you ever think about following in your father’s footsteps in pursuing a career in medicine?

Anthony: You know, I did for a hot minute and I think one day, my father perhaps was having a bad day. So, when I came home from school, having turned in, I was at grade schooler at the time, some human anatomy collage that I put together, I said, “Hey dad, I think I want to be a doctor when I grow up. ” And my father who really enjoyed his patients, he loved providing care in the communities where we lived, I think he was just having a bad day he said, “No son, you don’t want to be.” And talk about making an impression on a kid. I was like, “Oh, wow, I guess I don’t want to be that.” But I did grow up in a home where my father as a doctor really believed in public service, giving back to others. That’s what he did in his medical practice. So, instead of medicine, I chose the law.

Dr. O’Connor: Well, I will share that we know that health policy and the law is fundamentally and crucially important to health equity and how health is delivered in this country. So, I’m going to give you an honorary physician degree today on our podcast. How about that?

Anthony: All right. Sure.

Dr. O’Connor: Although you’re only in your second term in Congress, you’re certainly not new to politics or public service. Could you tell our audience a little bit about your military background, your service as well as your service as Lieutenant Governor of Maryland?

Anthony: Sure. Well, my public service did begin when I raised my right hand and accepted a commission as a Second Lieutenant in the United States Army. I flew helicopters with the Third Infantry Division in Germany in the mid-1980s. It was sort of the height of the Cold War. When I came off of active duty and I went to law school, I stayed in the army reserves and I ended up doing another 25 years in the reserves, for a total of 30 years in uniform service, including a tour of duty in Iraq. So, military service has a special place in my heart. The men and women who serve in uniform, some of the most patriotic people who I’ve ever met. It was just really an honor. When I came off of active duty, as I mentioned, I went to law school, I practiced law. I was with a big law firm, but I tended to do more pro bono work than anything else, helping the firm meet its pro bono goals. And representing indigent clients in low-level criminal court proceedings, in class action lawsuits, and things like that.

Then, I ran for Lieutenant Governor with Martin O’Malley and spent eight years as part of the O’Malley/Brown team where we did, I think, big things for Maryland in areas of the environment, education and I believe in the area of healthcare. We not only implemented at the state level the provisions of the affordable care act, but I think we did a lot to address health disparities in Maryland.

Dr. O’Connor: First, thank you for your service, most impressive, both in uniform and your service now as a public servant. Because I do personally think that service at that level is critically important and very honorable. So, thank you.

I want to turn now to the issue of the pandemic and the impact that the coronavirus has had, particularly on people of color. Maybe one of the only positive things I can say about this horrible nightmare of a pandemic is that it has heightened everyone’s awareness about social determinants of health and health inequity. Now, I know these are not new issues for you because you have a long history of being a champion for health equity and the innovative efforts that you’ve made to reduce health disparities. I want to focus for a minute on your work when you were Lieutenant Governor of Maryland when you began to establish Health Enterprise Zones, which I think are fantastic, innovative, and could serve as a model for us across the nation on trying to improve health equity. So, could you tell our audience a little bit about the Health Enterprise Zone Program in Maryland and where you came up with this idea and how it works?

Anthony: Sure. When I was Lieutenant Governor, Martin O’Malley asked me to focus on three broad areas. One was economic development, the other was higher education and the other was healthcare. As you suggested earlier, there’s an intersection of all of these policy areas and the impact or the influence on individual and public health. But in my work in economic development, both as Lieutenant Governor, and when I was in the General Assembly, we often looked at how do we stimulate or create activity in those communities where there are high rates of unemployment, there are high rates of poverty. There are other factors like high rates of suicide and drug use, etc. We believed in the economic development context and if we bring more jobs to those communities, you tend to sort of improve the socio-economic indicators. So, often you’ll hear about empowerment zones or economic empowerment zones, economic enterprise zones. So, as I was focusing on the healthcare portfolio, I started asking public health officials and others who are much more experienced in this area, “Do you think it makes sense if we’re going to address health disparities, if we perhaps incentivize providers to deliver services in underserved communities, much like we incentivize employers to bring jobs to communities.” Because I knew enough that access to health insurance is just one part of the equation. You can have insurance, but if you don’t have a provider in your neighborhood or your community that’s providing that primary care, and it doesn’t have to be a physician, it could be a non-physician provider, then typically you’re going to see greater disparities and a less healthy community.

So, we were implementing the Affordable Care Act, so then the question became, “What do we do to make sure that there’s actual access to care in these communities? Can we do something like Economic Empowerment or Economic Enterprise Zone?” The answer was yes, we could, and we should. So, we did. I worked with the General Assembly, worked with the community and I should say our county health officers community stakeholders in the public health space, and we designed this program and it was implemented in Maryland for, I think, three or four years. Unfortunately, Governor Hogan discontinued the program, but a study by Johns Hopkins revealed that it met its intended goals. It reduced hospital admissions. It delivered more access to care. It reduced the cost of care in that community and its improved health outcomes. So, we were really excited about the program and I’m glad to see that there are some members of the General Assembly, who, as you mentioned during this pandemic, have a heightened awareness of health disparities are looking at ways to extend that program or re-introduce it in Maryland.

Dr. O’Connor: Well, that indeed is encouraging. I’m discouraged that the program was discontinued but encourage that now it’s being considered to be reopened. In my opinion, we just have to start finding innovative ways of addressing these issues. Do you have a favorite success story or story about the program that you want to share with our audience?

Anthony: So, these enterprise zones, when we created them, we sat down with providers, we sat down with community health organizations and stakeholders and public health officials, and we said, what should the program look like? What would attract a provider into a community that they otherwise would not serve? That’s why we came up with a different, sort of a menu, of items that a provider could choose from. Some were outright grants to either install new equipment, improve your facility. Some of it included employee tax credits, also work opportunity tax credits for the employers themselves. Student loan repayments for both physician and non-physician providers and also a 10% bonus, if you will, in Medicaid reimbursement because we managed that at the state level. So, we designed it in collaboration. In terms of the success story, I don’t know if it’s sort of like an individualized or verticalized success story, but what struck me the most and what I was so excited about is none of the five zones that we created looked the same. They were all kind of tailored and adapted to the needs of that community.

In Annapolis, for example, they decided that they were going to focus a lot on a group of apartments that served an elderly population at higher incidences of hypertension and other coronary diseases, diabetes. There were many, many ambulance-runs, back and forth to that apartment building on any given day or week. So, they focused there, and we saw dramatic improvements.

Anthony: We had another one in Prince George’s County where it was determined that what really was one obstacle, not only the lack of a provider within these particular zip code, 20743, but the transportation network didn’t really support one of the areas that was believed to be optimal for a health provider to locate. So not only did we support that health provider with the various incentives I mentioned, but we worked with our local transportation department to get a bus stop there. And it just made all the difference as more and more people were able to access care. So, not necessarily an individualized success story, but just the sort of like the beautiful way in which this program was tailored to meet the needs of the communities.

So, we’ve tested it now, right? We had five zones. They all had great results validated by a study done by Hopkins. We’re ready at the federal level to no longer pilot it, but to really just incorporate it nationally. Let’s put some resources in there for $15 million in Maryland, the study came back and said, we saved close to $110 million in reduced hospital admissions. That’s a lot of savings that can go back into good quality care in underserved communities. It worked in Maryland. It can work anywhere around the country. That’s why I’ve introduced it in Congress.

Dr. O’Connor: Yes. I want the audience to appreciate and understand that you have now introduced a bill in Congress that will take this Health Enterprise Zone concept to the national level. So, can you tell us a little more about where the bill is in terms of the process and the stages of gaining support?

Anthony: I’ll share one experience. It’s a lot more cumbersome on Capitol Hill than it is in the halls of Annapolis, things take a lot longer to get across the finish line. I introduced the bill. I have support from many members of the Congressional Black Caucus. Robin Kelly out of Illinois, a big champion for health equity as a member of the Congressional Black Caucus and a member of Congress. I’ve got Steny Hoyer, the Majority Leader who rarely co-sponsors bills because of the leadership position he’s in. And you could imagine everybody wants Mr. Hoyer to co-sponsor their bill. So he tends not to co-sponsor many bills, but he made an exception here. So, he’s one of the co-sponsors.

So, we filed the bill and it’s been referred to a number of committees because there are tax pieces to it. So that’ll be ways and means. Energy and commerce get a lot of healthcare issues. There are a lot of important priorities that are being pursued right now, and it’s hard to get the attention particularly of my Republican colleagues who seem to be slowing things down particularly in the Senate to focus on important issues. We’re wrestling with trying to make progress on pandemic relief. I’d like to get that done but I’d also like to get my health disparities, my Health Enterprise Zone bill done. The truth of the matter is, it’s more likely to happen in the 117th Congress. I will re-introduce it. I’m very confident we’ll have Democrats who lead the house. It’s my hope that the same can be said in the Senate. I think under a Biden Administration where Vice President Biden has laid out a blueprint for black America, where he looks at health disparities, he understands, we’ve got to make structural changes if we’re going to make real progress, lasting progress. I’m confident that a Biden Administration would very much embrace this concept and we could get it across that finish line.

Dr. O’Connor: Well, I will state this in a totally bipartisan or nonpartisan way. This is such a critical issue that it needs to happen regardless of who has the House Majority or the Senate Majority, or who sits in the Oval Office. One of the things that I hope that we as citizens nationally have started to understand is that we are all connected. We cannot isolate ourselves from other people, from communities. So, if we don’t start to recognize that it matters to us and our families, even if we’re living in a more affluent area of the community, a more affluent section of town, lower-income areas where coronavirus is having a greater impact is still going to affect us. If a community is sick, everyone in that community is at risk. I’m hopeful that regardless of the outcome of the election, people are awakening to the need for us to address these disparities. It’s really nonpartisan.

Anthony: You’re absolutely right. Because health disparities are not just along racial and ethnic lines. There’s a geographic component to health disparities. That’s why one of our zones was actually in rural Maryland in Dorchester County. We know that communities that are predominantly white that have higher incidences of chronic disease because of a lack of health services or for other social determinants of health outcomes. So, this is not a partisan issue. It’s not even really a racial or ethnic issue. It’s just an issue.

There are disparities that exist often along racial and ethnic lines, often along geographic lines. The bottom line is whether you’re Republican or Democrat, you should want to ensure that every American has access to quality, affordable care, has an opportunity to live a healthy and meaningful life, which means a more productive life, both at home and in the workplace. So it is my hope, and I know that I did earlier say that we’re being a little stonewalled by Republicans in the Senate, but that’s more of a generic comment that nothing’s moving in the Senate. The Senate is controlled by Republicans, but I do think that Republicans and Democrats can get together and should get together on this program.

Dr. O’Connor: Amen. I’m a voter and I feel that it is everyone’s responsibility to do this. It is so clear to me with the horrible deaths that we’ve seen in the pandemic that we simply have to get serious about addressing health equity. And you’re absolutely correct, Congressmen. This isn’t about race or ethnicity. Although we know there are differential impacts depending on the community. We see these disparities in white people in rural America, as well. So, absolutely, could not agree more. Those were fabulous comments.

I know that we’re getting a little close to our time and I want to be respectful of your time. We’re so appreciative of your generosity. Let me close with asking about other ideas that you might have for us to better address health disparities or promote health equity in the country.

Anthony: Sure. As we both mentioned earlier on, there’s this intersectionality between different policy areas. So, I think about a city like Baltimore, I had the privilege to work for them as Lieutenant Governor. Baltimore is no longer in my district. It’s one of the least connected metropolitan areas in the country. And as our health enterprise zone demonstrated in Prince George’s County, that a lack of transportation often contributes to a lack of access to healthcare and poor health outcomes.

So, when we talk about H.R.2, which is Moving America Forward, that’s our big infrastructure investment bill in the House of Representatives. That’s important. People don’t think necessarily about transportation, infrastructure as helping address health outcomes. When we can connect cities like Baltimore, when we can connect folks in rural America to services and resources, you’re going to improve health outcomes.

Anthony: So, passing or making those infrastructure investments has to be a priority. So, that’s just one other example of the kinds of things that we can do. We are on the floor today in the House of Representatives voting on the Strength in Diversity Act, dealing with diversity and inclusion in education. The way the program is designed, it will also support food security in our schools. You can’t possibly teach a child to learn if they’re having difficulty listening to their teacher, because they’re listening to their stomach because their stomach is talking to them because it’s empty.

There are things that we can do to address food insecurity, both in our schools and in the community, and that has an impact on health outcomes as well. So, when we think about addressing health disparities, it’s not just in the narrower sort of laws that we pass that deal with health programs and health institutions and health workers but it’s transportation. It is education. It’s policies that impact the environment that have an impact on the health outcome in our community. So, we’ve got to take a holistic approach to address health disparities.

Dr. O’Connor: We agree completely. You know, around what we call our vicious cycle, whereof joint pain, leading to immobility and obesity and the development of hypertension, diabetes, heart disease, depression, and a very sick patient, which can happen to anyone. You could be an affluent CEO, male CEO, but we know people that are more likely to get trapped in this cycle are women and individuals of color and those of lower socioeconomic means because around that vicious cycle are these social determinants of health that you’ve just spoken about and around them come policy, right? So, your efforts to address policy to impact and improve social determinants is absolutely going to improve health equity. I want to thank you for all of your efforts, for your courage and determination to address these critical issues for our communities and our nation.

Anthony: Dr. O’Connor, thank you very much for having me on and to be able to participate in this conversation. Very important issue. I’m glad that you’re doing the work that you’re doing in this space. Thank you.

Dr. O’Connor: My pleasure. We look forward to supporting your Health Enterprise Zone Legislation.

Anthony: Outstanding. Thanks.

Dr. O’Connor: Thank you. Have a wonderful day.

Anthony: You too. Bye-Bye.

(End of recording)

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