The Robert Wood Johnson Foundation defines health equity as everyone having an opportunity to be as healthy as possible. This requires removing obstacles to health, such as poverty, discrimination, and powerlessness. Equity calls for access to good jobs with fair pay, quality education, housing, safe environments, and access to healthcare. The CDC considers health equity as achieved when every person can attain his or her full health potential — no one is disadvantaged because of social position or circumstances.
The Roots of Health Inequities
It’s beneficial for CMOs to understand the historical policies that have led to disparities in health equity. The foundations of the United States were built on a racial class/caste system. Marginalized individuals, such as people of color, were subjected to medical and surgical experiments without consent. After emancipation, medical care for those who were formerly enslaved was substandard. Segregation led to their inability to seek care at major hospitals and health systems. This perpetuated inequities in access to healthcare.
Other historical factors affected access to healthcare and healthcare equity, including:
Racism. Physician and epidemiologist Camara Jones defines racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks.(1) That system leads to unfairly disadvantaging some individuals and communities and unfairly advantaging others. This, in turn, saps the strength of the whole society through the waste of human resources. When talking about racism, it is important to use words such as systemic or structural because this avoids singling out an individual character flaw or a personal moral failing.
Redlining. Redlining is a discriminatory practice of denying services such as mortgages, insurance, loans, or other financial services to residents based on their race or ethnicity. Historically, redlining was used to maintain the homogeneity of certain communities. Often the individuals who were excluded were then confined to specific areas of the community with limited resources such as housing, jobs, and education. This perpetuated inequities, including within the healthcare sector.
Gerrymandering. Gerrymandering is manipulating the boundaries of an electoral constituency to favor one party or class. These practices have been used to keep resources within privileged areas and reduce resources in marginalized areas.
Housing, industrial, and environmental disparities. The practices of redlining and gerrymandering have led to fewer resources available to certain communities, resulting in housing disparities where marginalized communities are unable to purchase real estate. These areas could also be targeted for industrial development and environmental hazards that reduce the overall health of the community — manifested specifically in asthma, respiratory symptoms, and cancer.
Voter suppression. Voter suppression is a result of gerrymandering and under-allocation of resources.
Reduction in tax revenue. Areas affected by the above tactics are consistently under-resourced. Tax revenue funds community resources such as parks and recreation, the public school system, and community outreach programs. As a result, poorer areas have a reduced tax base, which perpetuates systemic inequity.
Underperforming schools. Schools that are under-resourced produce students with lower academic achievement. These schools have higher dropout rates, lower test scores, worse placement on standardized testing, and a lower number of students who attend colleges and universities. Such individuals are qualified only for low-wage, unskilled employment. Again, this is a cycle that leads to fewer resources to purchase healthful foods, health insurance, or the ability to relocate to a different area.
Historical and Modern U.S. Healthcare Policies
The federal government has tried to improve health equity. The Hill-Burton Act of 1946 required healthcare facilities to serve all persons without consideration of race. In practice, facilities were often racially separate and were not equal. Despite the intentions of the federal legislature, many hospitals continued perpetuating inequities in healthcare.
The medical assistance for the aged program (Medicaid) was funded by the federal government to provide healthcare to the poor. However, this program was grossly underfunded, and there is scarce participation by states with a large number of persons of color.
The Department of Health and Human Services, founded in 1953, promoted racial integration of hospitals. It provided funds to encourage physicians, hospitals, and other providers to care for underserved communities. The results were diminished, however, as the federal government gave states the flexibility to underfund Medicaid or limit its eligibility. This limited certain groups from qualifying for healthcare coverage.
In the U.S., most individuals receive their healthcare financing via employers, the federal government, or states; far fewer individuals purchase their health insurance plans individually. Employer-sponsored plans constitute about 60% of insurance coverage.
A significant number of individuals are the working poor who are not offered insurance from their employers but whose wages are too high to qualify for Medicaid. Because they can’t afford a private healthcare plan, they are caught in a no man’s land of access to medical insurance.
The Affordable Care Act (ACA) sought to remedy this situation by expanding Medicaid to individuals under age 65 with an income of less than 133% of the federal poverty level. However, on June 28, 2012, the U.S. Supreme Court issued its decision in the case challenging the ACA. A majority of the Court found the ACA’s Medicaid expansion unconstitutionally coercive of states. The ruling left the ACA’s Medicaid expansion intact in the law, but the practical effect of the Court’s decision made the Medicaid expansion optional for states.
To date, 37 states have taken the deal. However, a block of states in the Deep South continues to resist. Medicaid politics in the South is intertwined with issues of race, class, and political party in ways that make approval by these legislatures unlikely.(2)
Reimbursement and Quality
Many healthcare organizations receive payments to offset uncompensated or undercompensated care. However, the funds are directed by the state with minimal federal oversight. Consequently, the funds may not go to the facilities with the most need.
Most CMOs are familiar with value-based payments and their effort to improve quality and reduce costs. However, these payments often don’t consider unequal social structures. Health systems in under-resourced areas often spend more time and have more encounters with patients. Even so, those individuals are often unable to achieve the metrics to qualify for the highest value-based incentives. Pay-for-performance programs advantage providers who care for individuals in more affluent areas. Those regions have more resources to achieve their targets.
It is important that CMOs understand that healthcare quality within their systems is directly related to equity. Facilities that are not achieving their quality metrics should take a close look at factors that reflect equity. Certain racial or ethnic groups are less likely to receive quality care. Children in communities of color are less likely to have appendectomies prior to rupture. Asthmatic patients in those communities have disproportionately worse outcomes. Outcomes are worse for coronary artery bypass grafting, kidney transplantation, screening for breast and colon cancer, mental health treatments, and pain management for African Americans.
Under-resourced areas have shortages of primary care physicians, surgeons, and mental health providers. The closure of public and nonprofit hospitals in urban and rural areas has led to access disparities. Our safety net facilities are often significantly under-resourced and financially constrained. These facilities frequently have low patient satisfaction scores, underperform on evidence-based metrics, and have higher rates of adverse safety events and complications. It is important that healthcare leaders not cast undue blame.
Key Steps, Key Concepts
Eliminating health disparities to promote health equity will require resources from all levels of the government and society and must be a continuous practice for generations to come. Key steps for chief medical officers include:
Identify health disparities;
Change and implement policies, laws, systems, environments, and practices to reduce inequities;
Evaluate and monitor results utilizing short- and long-term measures; and
Reassess strategies and outcomes and plan for the next steps.
Chief medical officers should understand the three pillars of health equity: workforce, patient outcomes, and community efforts.
Pillar 1: Workforce
Improving the diversity of the medical workforce is one key step to improving health equity. Academic centers and medical schools should strive to have workforce and student populations that look like the population they serve. That goal entails robust efforts centered around diversity, equity, and inclusion, and recruiting a diverse student body. Pipeline programs for underrepresented students, such as summer programs and enrichment programs, are key to this effort. It would be beneficial to partner with historically black colleges and universities in those areas.
Mentorship is another way to improve medical workforce diversity. It can be done on levels from high school through professional rounds. This would expose individuals to various healthcare positions.
Most important is financial support. Marginalized individuals are financially under-resourced, and pursuing a career in the medical field may present a steep financial hurdle. It’s important to set up scholarships and provide grant funding. Healthcare organizations should also consider loan repayment and forgiveness programs.
Healthcare executives should understand that there are significant disparities in medical education. A number of biases affect learners in medical education, and a disproportionate number of students and residents from under-represented groups do not graduate. It is important to support diverse faculty and help them transition into leadership roles.
Organizations may successfully recruit those individuals only to fall short of making them feel included or well-integrated once they arrive. Therefore, they need to focus on retention as well as recruiting. Diverse, equitable, and inclusive language should be included on all of the healthcare organization’s websites and communications.
Hospitals and health systems should aim for their workforce as well as their leadership to reflect the community they serve. Organizations should strive to be the healthcare employer of choice for their staff as well as the provider of choice for their patients. It is important to demonstrate community benefit and show where those funds are going.
Pillar 2: Patient Outcomes
Chief medical officers occupy a unique position: They can review data and enact change that influences health equity. It is important to collect data on race, sex, gender identity, and geographic location to improve outcomes in chronic disease management and maternal and infant health. Healthcare systems should reinforce the importance of cultural competency training for all employees and contractors to increase awareness of implicit bias. Patient experience scores should be evaluated before and after competency training and stratified by race, ethnicity, and language preference.
Pillar 3: Community Efforts
CMOs have an obligation to engage with community partners to align hospital priorities with community needs. We need to develop plans for targeted intervention. Engaging state and local elected officials is critical for success. Often hospitals are the source of truth for healthcare data. It is important to engage with lawmakers to begin an open dialogue on policy and lawmaking. Invite them to your organization so they can get a first-person view of the encounters and experiences of patients.
Quality Outcomes and Health Equity
There is a direct link between quality outcomes and health equity. Studies estimate that clinical care impacts only 20% of the county-level variation in health outcomes, while social determinants of health affect as much as 50%.(3) We also know that life expectancy can vary by as much as 25 years between neighborhoods.(4) Health is foundational to a vibrant society.
A 2011 analysis estimated that eliminating health disparities for minorities would have reduced direct medical care expenditures by about $230 billion and indirect costs associated with illness and premature death by more than $1 trillion for the years 2003–2006.(5) Diverse teams offer more accurate diagnoses, higher patient satisfaction, and gain greater patient compliance. Diverse teams have decreased healthcare costs.
The CMO’s engagement with local health departments as well as community programs can influence the healthcare outcomes in the areas they serve. Diverse professionals and cross-sectional partnerships should be developed to connect services as well as systems.
Population Health
To affect population health, CMOs must understand their own implicit biases and commit to eliminating them. The CMO should engage in mentorship, champion a diverse community of medical professionals, and participate in hospital committees that promote equity and improve patient safety, morbidity, and mortality. The CMO should be actively engaged in their community and provide education, partner with local community leaders and faith leaders, partner with charitable organizations and serve on their boards, and engage with lawmakers to advocate for policy changes.
Improving health equity requires the ongoing involvement of the entire community. Health equity cannot be addressed without considering policies rooted in racism that have caused housing inequities, environmental disparities, and under-resourced communities.
Diversifying the medical workforce is one key step that can help improve health equity. It is important for hospitals and health systems to conduct adequate needs assessments and partner with community groups to improve health equity in the areas they serve. Physicians and other healthcare professionals must understand the importance of equity and act on a personal, professional, and community level to improve the lives of the patients they serve.
Excerpted from The Chief Medical Officer’s Essential Guidebook, edited by Mark D. Olszyk, MD, MBA, CPE.
References
Jones CP. Toward the science and practices of anti-racism: launching a national campaign against racism. Ethn Dis. 2018;28(Suppl 1): 231–234. https://doi.org/10.18865/ed.28.S1.231
Jones DK. Will the Deep South ever expand Medicaid? Would it matter? The Milbank Quarterly. December 2019. www.milbank.org/quarterly/articles/will-the-deep-south-ever-expand-medicaid-would-it-matter . https://doi.org/10.1111/1468-0009.12430
Whitman A, De Lew N, Chappel A, et al. Addressing social determinants of health: examples of successful evidence-based strategies and current Federal efforts. ASPE Report. ASPE Office of Health Policy, U.S. Department of Health and Human Services. April 1, 2022. https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf .
Your neighborhood could affect your life expectancy by up to 25 years. WCPO Cincinnati. February 22, 2020.
LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequities in the United States. Int J Health Serv. 2011;41(2):231–238. https://doi.org/10.2190/HS.41.2.c