Jeffrey Okewunmi and Sigal Israilov
Jul 14, 2020
International conversations about systemic racism highlight the oppression Black people face in America and in the American healthcare system. Structurally racist policies such as redlining, community policing, and school segregation exclude Black communities from opportunities — including the opportunity for health equity. This has never been more clear: racism is a public health issue. Across the board, Black patients are sicker and die earlier than other racialized groups. A multitude of factors contributes to overall health, including weathering — which is a state of heightened health vulnerability resulting from lifetime exposure to the chronic stress of discrimination. Ultimately, then, racism is shortening Black lives. To combat this pattern and address these disparities, healthcare providers must acknowledge that race and racism influence both health and healthcare.
Changes to policies and systems can serve as strategic approaches to reducing and eventually eliminating disparities in health and healthcare. But despite efforts to do this starting two decades ago, racial disparities still exist and persist today.
A major attempt to improve health equity was the Affordable Care Act (ACA). Efforts to reduce disparities provisioned within the ACA included: broad coverage expansions, increased funding for community health centers, creation of the Offices of Minority Health within the U.S. Department of Health and Human Services, funding for health care professional cultural competence training and education, and prevention and public health initiatives. The effort engaged local communities, private organizations, and provided efforts to address health disparities and focus on social factors that contribute to the individual health experience. The combination of these efforts created an infrastructure to better support care providers with resources to effectively target health disparities. However, policy changes in recent years have reversed the progress made by initiatives outlined in the ACA. Efforts to shift the focus of payment and delivery system models towards value and outcomes instead of services have diminished, in addition to reduced funding for prevention and public health.
While the ACA was a solid starting point in expanding access to care, the provision of health services for Black communities, in particular, remains an area for improvement. This is rooted in multiple factors, including justified historic mistrust in the healthcare system, fewer available primary care and specialty providers in predominantly Black counties, subpar inclusion of Black patients in clinical trials, training of medical algorithms based on white patients’ data, a relative sparsity of Black physicians, and environmental challenges including air pollution and food deserts.
Exacerbating these barriers is the health insurance coverage gap that disproportionately impacts Black communities. Even though the passage of the ACA in 2014 reduced coverage disparities for Blacks by 5.1% in its first year, this primarily benefited people living in states that expanded their Medicaid programs. The ACA allows but does not require, states to widen the Medicaid income eligibility window. Residents of the 13 states that have not expanded Medicaid, in other words, are more likely to have an income that’s too high for Medicaid yet too low for a private Marketplace plan. Interestingly, these states have some of the largest Black populations in the nation. As a result, 15% of uninsured Blacks fell into the coverage gap in 2018 — more than any other race or ethnicity. This has a direct negative impact on the health of these communities, as a lack of insurance coverage leads to care avoidance and worse outcomes for diseases such as asthma, hypertension, and diabetes.
Since public funding alone has struggled to address the needs of Black communities, there is promise in private-public partnerships to address disparities in care. By incentivizing business models to meet this need, states can facilitate both innovation and improved community health. An example of the success of such a partnership are Medicaid Managed Care Organizations (MCOs), which are currently in place in most states and cover over two-thirds of all Medicaid beneficiaries. MCOs engage in risk-based contracts with the state, receiving a set (capitated) price per patient per month in exchange for the provision of care services for the state’s Medicaid patients. Through these contracts’ publicly available comparison data, MCOs are incentivized to deliver high quality, community-based care. Metrics being tracked in various MCOs include chronic disease management, perinatal/birth outcomes, and mental health measures. Because improving these metrics necessitate collaboration and coordination beyond the traditional bounds of “hospital services”, an increasing number of MCOs provide pharmacy benefits, behavioral health coverage, and social services including housing, nutrition, education, and employment.
The Managed Care model shifts risk onto MCOs, incentivizing them to use creative solutions to improve outcomes of care. This creates a market for startups to invest in the delivery of Medicaid services. From streamlining care management to tracking quality data and everything in between, the private sector is invested in the performance of Medicaid plans. MCOs are a proof of concept that addressing social determinants of health can be an attractive business model that benefits insurers and communities alike. As the national discussion around structural racism takes shape, private-public collaborations may be part of the solution to address health inequity. The same paradigm has the potential to drive innovation in healthcare on an even larger scale, particularly as more payers transition to value-based care.
Sigal Israilov is an MS4 at the Icahn School of Medicine at Mount Sinai with an interest in healthcare value and patient safety as they relate to racial disparities in care.
Jeffrey Okewunmi is an MS2 at the Icahn School of Medicine at Mount Sinai within an interest in reducing disparities across the continuum of care.