Feature
Making the invisible visible
When it comes to addressing racial inequities, the health care system faces a conundrum. As Georges Benjamin puts it, “Eighty percent of what affects health occurs outside of the doctor’s office.”
Benjamin is executive director of the American Public Health Association and one of four editors of the “Ending Unequal Treatment,” a 374-page report published this summer by the National Academies of Sciences, Engineering, and Medicine. The publication is a follow-up to “Unequal Treatment,” the 2003 landmark study by the Institutes of Medicine. That report found that people of color experienced worse health outcomes regardless of their economic circumstances, and it first put the issue of racial inequities in health care on the map. Its recommendations focused on ending racism in the health care system.
In the ensuing two decades, however, little progress has been made in closing those gaps. “We certainly found there has been progress, but it’s been uneven and inconsistent,” Benjamin says.
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Benjamin and his coauthors understood that, this time around, they had to grapple with challenges bigger than—and ultimately outside the control of—the health sector. They are challenges both social and structural, either directly caused or exacerbated by structural racism—challenges like racial profiling in the criminal justice system, housing and food insecurity (especially as a result of historic redlining and job discrimination), and pollution and other environmental injustice, which require a different approach from the health system to address. “The injustices we see are based on the way the system is designed, financed, and delivered,” he says. “You are not going to fix them unless you fix the fundamental structural inequities we have in our system.”
The solutions the report recommends are ambitious: expanding access to health insurance (and making Medicaid reimbursement rates more equitable); collecting racial data more systematically; researching and supporting more team- and community-based interventions; and enforcing equity-based outcomes with stricter accountability.
Diversifying data
Benjamin says one easy way to improve data collection about race—and thus reveal patterns in outcomes, better allowing for accountability on equity in health outcomes—would be to include racial information on billing forms. “The tools are there, the technology is there, but we have not invested in the systems to do it,” he says.
University of Minnesota Professor Rachel Hardeman, who directs the Center for Antiracism Research for Health Equity, agrees it’s important to “make the invisible visible” through a “robust and rigorous data infrastructure.” Hardeman began her own work in the field after reading the first Unequal Treatment report in grad school. But she isn’t convinced that the latest report goes far enough. Hardeman would like to see the collection of more qualitative and anecdotal data, particularly from patients who experience interventions that improve care. “It’s not just about the quantitative numbers and logistic regressions,” she says. “We also have to be thinking about the people and the stories behind … every P value.”
Expanding access
Reducing the number of people lacking medical insurance, who are overwhelmingly racial minorities, should be a priority, the report says. “The biggest issue is improving access to care,” agrees Lisa Cooper, a professor at Johns Hopkins Bloomberg School of Public Health and the founding director of the John Hopkins Center for Health Equity, who also served as a reviewer on the report. “Physicians are hampered in what they can do by knowing people don’t actually have the coverage to pay for needed tests and therapies.” (The original report controlled for insurance status, looking at inequities in treatment based on racial bias; the new report examines insurance access as a systemic issue that contributes to inequities in care.)
While the Affordable Care Act (ACA) has dramatically expanded coverage, ten states have not expanded Medicaid, the joint state-federal program for people with low incomes. Many of them are southern states with conservative legislators who have long opposed the ACA on ideological grounds—states that also have large Black and Latino communities. According to a recent Congressional analysis, 1.6 million people in those states are unable to afford insurance; two-thirds of those for whom insurance is a challenge are people of color. Four of those 10 states are also among those reporting the highest level of inequities in patient outcomes. In those cases, the report notes, patients often rely on emergency care, which is both more expensive and less effective than upstream preventative care. Even states that have expanded Medicaid often don’t reimburse at the same rates as the federal Medicare program for seniors, leading to gaps in coverage and denial of care. The report recommends closing this gap to increase the number of people who can access high-quality care.
Greater investment in community-based solutions may also expand access to health. Studies have found that community health workers can be particularly effective with minority populations, both by providing culturally appropriate care and helping to address neglected issues arising from poverty, food or housing insecurity, incarceration, and other issues more likely to affect communities of color.
“There is so much incredible work happening in the communities in little pockets all across the country,” says Hardeman. As an example, she points to the Roots Community Birth Center in Minneapolis, run by and for Black women, which customizes a birthing plan for individuals’ needs. In a recent study of the center, cited in the “Ending Unequal Treatment” report, Hardeman found that it achieved much better outcomes for women of color, with zero preterm births for 284 families in four years. Such models, however, are not well-funded by traditional payment methods. “If there were funding for coordinated and sustainable efforts, I think we would be having very different discussions right now,” Hardeman says.
One positive development, says Cooper, are offices within hospitals that are partnering with outside entities to collaborate on care. “[It is] in the common interest of so many different groups to identify each sector’s role,” she says. “What does the health system do best that it should continue to do, and what can other people, systems, and organizations do in a more effective way?”
Still a ways to go
“Ending Unequal Treatment” is less sanguine about unconscious bias trainings meant to reduce inequities in quality of care and often implemented in medical school or health care settings. While there is strong evidence that implicit bias exists, the evidence about effectiveness of trainings has been mixed. Cooper remains optimistic. “It’s not that it’s ineffective; it’s just that the data are inconclusive,” she says.
Even interventions with good data behind them face hurdles. One major impediment, says Commonwealth Fund President Joseph Betancourt, is that they tend to be funded by foundations—and when the grants dry up, so do the interventions. “We’ve known for a long time that community health workers, health navigators, and health care coaches improve health outcomes,” says Betancourt, who is also an associate professor of medicine at Harvard Medical School and an author of the original “Unequal Treatment” report. Because there isn’t “sustainable financing,” he says, “we are not integrating these successful models into the system.”
Health care, meanwhile, has made strides in quality of care thanks to innovations such as accountable care organizations, which reimburse costs based on patient outcomes, rather than a traditional pay-for-service model. Without taking equity into account, however, such models can actually increase disparities by incentivizing systems not to treat individuals with more complex medical problems, who are more likely to be racial minorities. “If you have these systems that allow people to cherry pick who they care for based on the way they are designed and paid for,” says Benjamin, “then they are driven by a desire to improve revenues over improving care as the primary goal.”
The report recommends embedding equity measures into such models, making equity in outcomes across racial populations a factor not only in how systems are paid, but in how doctors are licensed and hospitals are accredited. “We need to be thinking about racialized health equity outcomes in the accreditation process and payments and bonuses, and embed anti-racism into accountable care models,” Hardeman says. “We haven’t even scratched the surface of this because we haven’t wanted to shake the status quo.”
Ongoing backlash against diversity, equity, and inclusion efforts meant to improve racial justice could make it more difficult to implement some of the report’s recommendations. But its authors don’t shy away from denouncing that backlash. “We should not accept the mistaken assumption that when you give one group of people better care, it takes away from other people’s needs,” Benjamin says.
The biggest impediment to the report’s recommendations is federal funding. Many recommendations would require Congress or state legislators to earmark additional revenue for data collection, Medicaid reimbursement, and discrimination enforcement; they also require government or insurers to supply sustainable funding for health care interventions. Benjamin, however, is optimistic that many of the report’s recommendations could be accomplished by redirecting funds, rather than increasing them. “I’m hoping the next administration and Congress will recognize that health care costs under the current system are going through the roof, but if they follow the recommendations we put in place, they can get better care at lower cost,” he says.
Betancourt agrees. “It’s not necessarily about spending more,” he says, “it’s about spending the resources we have in a smarter way for better outcomes.”
Top image: Ellagrin / iStock
Republish this article
<p>How better data, more access, and community-based solutions can drive health equity</p>
<p>Written by Michael Blanding</p>
<p>This <a rel="canonical" href="https://harvardpublichealth.org/equity/follow-up-to-unequal-treatment-report-has-plan-for-health-inequity/">article</a> originally appeared in <a href="https://harvardpublichealth.org/">Harvard Public Health magazine</a>. Subscribe to their <a href="https://harvardpublichealth.org/subscribe/">newsletter</a>.</p>
<p class="has-drop-cap">When it comes to addressing racial inequities, the health care system faces a conundrum. As Georges Benjamin puts it, “Eighty percent of what affects health occurs outside of the doctor’s office.”</p>
<p>Benjamin is executive director of the American Public Health Association and one of four editors of the "<a href="https://nap.nationalacademies.org/catalog/27820/ending-unequal-treatment-strategies-to-achieve-equitable-health-care-and" target="_blank" rel="noreferrer noopener">Ending Unequal Treatment</a>," a 374-page report published this summer by the National Academies of Sciences, Engineering, and Medicine. The publication is a follow-up to "Unequal Treatment," the 2003 landmark study by the Institutes of Medicine. That report found that people of color experienced worse health outcomes regardless of their economic circumstances, and it first put the issue of racial inequities in health care on the map. Its recommendations focused on ending racism in the health care system.</p>
<p>In the ensuing two decades, however, <a href="https://harvardpublichealth.org/alumni-post/revisiting-the-unequal-treatment-report-20-years-later/" target="_blank" rel="noreferrer noopener">little progress has been made</a> in closing those gaps. “We certainly found there has been progress, but it’s been uneven and inconsistent,” Benjamin says.</p>
<p>Benjamin and his coauthors understood that, this time around, they had to grapple with challenges bigger than—and ultimately outside the control of—the health sector. They are challenges both social and structural, either directly caused or exacerbated by structural racism—challenges like racial profiling in the criminal justice system, housing and food insecurity (especially as a result of historic redlining and job discrimination), and pollution and other environmental injustice, which require a different approach from the health system to address. “The injustices we see are based on the way the system is designed, financed, and delivered,” he says. “You are not going to fix them unless you fix the fundamental structural inequities we have in our system.”</p>
<p>The solutions the report recommends are ambitious: expanding access to health insurance (and making Medicaid reimbursement rates more equitable); collecting racial data more systematically; researching and supporting more team- and community-based interventions; and enforcing equity-based outcomes with stricter accountability.</p>
<h2 class="wp-block-heading" id="h-diversifying-data">Diversifying data</h2>
<p>Benjamin says one easy way to improve data collection about race—and thus reveal patterns in outcomes, better allowing for accountability on equity in health outcomes—would be to include racial information on billing forms. “The tools are there, the technology is there, but we have not invested in the systems to do it,” he says.</p>
<p>University of Minnesota Professor Rachel Hardeman, who directs the Center for Antiracism Research for Health Equity, agrees it’s important to “make the invisible visible” through a “robust and rigorous data infrastructure.” Hardeman began her own work in the field after reading the first <em>Unequal Treatment</em> report in grad school. But she isn’t convinced that the latest report goes far enough. Hardeman would like to see the collection of more qualitative and anecdotal data, particularly from patients who experience interventions that improve care. “It’s not just about the quantitative numbers and logistic regressions,” she says. “We also have to be thinking about the people and the stories behind … every P value.”</p>
<h2 class="wp-block-heading" id="h-expanding-access">Expanding access</h2>
<p>Reducing the number of people lacking medical insurance, who are overwhelmingly racial minorities, should be a priority, the report says. “The biggest issue is improving access to care,” agrees Lisa Cooper, a professor at Johns Hopkins Bloomberg School of Public Health and the founding director of the John Hopkins Center for Health Equity, who also served as a reviewer on the report. “Physicians are hampered in what they can do by knowing people don’t actually have the coverage to pay for needed tests and therapies.” (The original report controlled for insurance status, looking at inequities in treatment based on racial bias; the new report examines insurance access as a systemic issue that contributes to inequities in care.)</p>
<p>While the Affordable Care Act (ACA) has dramatically expanded coverage, ten states have not expanded Medicaid, the joint state-federal program for people with low incomes. Many of them are southern states with conservative legislators who have long opposed the ACA on ideological grounds—states that also have large Black and Latino communities. According to a <a href="https://www.cbpp.org/research/health/closing-medicaid-coverage-gap-would-help-diverse-groups-and-reduce-inequities">recent Congressional analysis</a>, 1.6 million people in those states are unable to afford insurance; two-thirds of those for whom insurance is a challenge are people of color. Four of those 10 states are also among those reporting the highest level of inequities in patient outcomes. In those cases, the report notes, patients often rely on emergency care, which is both more expensive and less effective than upstream preventative care. Even states that have expanded Medicaid often don’t reimburse at the same rates as the federal Medicare program for seniors, leading to gaps in coverage and denial of care. The report recommends closing this gap to increase the number of people who can access high-quality care.</p>
<p>Greater investment in community-based solutions may also expand access to health. Studies have found that community health workers can be particularly effective with minority populations, both by providing culturally appropriate care and helping to address neglected issues arising from poverty, food or housing insecurity, incarceration, and other issues more likely to affect communities of color.</p>
<p>“There is so much incredible work happening in the communities in little pockets all across the country,” says Hardeman. As an example, she points to the Roots Community Birth Center in Minneapolis, run by and for Black women, which customizes a birthing plan for individuals’ needs. In a <a href="https://pubmed.ncbi.nlm.nih.gov/31371235/">recent study</a> of the center, cited in the "Ending Unequal Treatment" report, Hardeman found that it achieved much better outcomes for women of color, with zero preterm births for 284 families in four years. Such models, however, are not well-funded by traditional payment methods. “If there were funding for coordinated and sustainable efforts, I think we would be having very different discussions right now,” Hardeman says.</p>
<p>One positive development, says Cooper, are offices within hospitals that are partnering with outside entities to collaborate on care. “[It is] in the common interest of so many different groups to identify each sector’s role,” she says. “What does the health system do best that it should continue to do, and what can other people, systems, and organizations do in a more effective way?”</p>
<h2 class="wp-block-heading" id="h-still-a-ways-to-go">Still a ways to go</h2>
<p>"Ending Unequal Treatment"<em> </em>is less sanguine about unconscious bias trainings meant to reduce inequities in quality of care and often implemented in medical school or health care settings. While there is strong evidence that implicit bias exists, the evidence about effectiveness of trainings has been mixed. Cooper remains optimistic. “It’s not that it’s ineffective; it’s just that the data are inconclusive,” she says.</p>
<p>Even interventions with good data behind them face hurdles. One major impediment, says Commonwealth Fund President Joseph Betancourt, is that they tend to be funded by foundations—and when the grants dry up, so do the interventions. “We’ve known for a long time that community health workers, health navigators, and health care coaches improve health outcomes,” says Betancourt, who is also an associate professor of medicine at Harvard Medical School and an author of the original "Unequal Treatment" report. Because there isn’t “sustainable financing,” he says, “we are not integrating these successful models into the system.”</p>
<p>Health care, meanwhile, has made strides in quality of care thanks to innovations such as accountable care organizations, which reimburse costs based on patient outcomes, rather than a traditional pay-for-service model. Without taking equity into account, however, such models can actually increase disparities by incentivizing systems <em>not</em> to treat individuals with more complex medical problems, who are more likely to be racial minorities. “If you have these systems that allow people to cherry pick who they care for based on the way they are designed and paid for,” says Benjamin, “then they are driven by a desire to improve revenues over improving care as the primary goal.”</p>
<p>The report recommends embedding equity measures into such models, making equity in outcomes across racial populations a factor not only in how systems are paid, but in how doctors are licensed and hospitals are accredited. “We need to be thinking about racialized health equity outcomes in the accreditation process and payments and bonuses, and embed anti-racism into accountable care models,” Hardeman says. “We haven’t even scratched the surface of this because we haven’t wanted to shake the status quo.”</p>
<p>Ongoing backlash against diversity, equity, and inclusion efforts meant to improve racial justice could make it more difficult to implement some of the report’s recommendations. But its authors don’t shy away from denouncing that backlash. “We should not accept the mistaken assumption that when you give one group of people better care, it takes away from other people’s needs,” Benjamin says.</p>
<p class=" ">The biggest impediment to the report’s recommendations is federal funding. Many recommendations would require Congress or state legislators to earmark additional revenue for data collection, Medicaid reimbursement, and discrimination enforcement; they also require government or insurers to supply sustainable funding for health care interventions. Benjamin, however, is optimistic that many of the report’s recommendations could be accomplished by redirecting funds, rather than increasing them. “I’m hoping the next administration and Congress will recognize that health care costs under the current system are going through the roof, but if they follow the recommendations we put in place, they can get better care at lower cost,” he says. </p>
<p class=" t-has-endmark t-has-endmark">Betancourt agrees. “It’s not necessarily about spending more,” he says, “it’s about spending the resources we have in a smarter way for better outcomes.”</p>
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