Structural Racism In Historical And Modern US Health Care Policy

Structural Racism In Historical And Modern US Health Care Policy

Health Affairs

Ruqaiijah Yearby, Brietta Clark, and José F. Figueroa

Abstract

The COVID-19 pandemic has illuminated and amplified the harsh reality of health inequities experienced by racial and ethnic minority groups in the United States. Members of these groups have disproportionately been infected and died from COVID-19, yet they still lack equitable access to treatment and vaccines. Lack of equitable access to high-quality health care is in large part a result of structural racism in US health care policy, which structures the health care system to advantage the White population and disadvantage racial and ethnic minority populations. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality.

Segregated hospitals are killing Black people. Data from the pandemic proves it

Segregated hospitals are killing Black people. Data from the pandemic proves it.

The Washington Post

David A. Asch and Rachel M. Werner

If Black patients hospitalized with covid-19 were cared for in the same hospitals where White patients went, their mortality rate would have been 10 percent lower.

That’s the conclusion of a newly published study we authored in JAMA Network Open. In it, we look at data from 44,000 patients hospitalized with the disease from January through Sept. 21, 2020. Unlike prior studies based on single health system data, our study examined a diverse set of nearly 1,200 hospitals across 41 states and D.C.

Conventional wisdom holds that these survival differences arise because Black Americans have higher rates of chronic health conditions and social risk factors than White Americans. It is true that hypertension, diabetes and poverty are more common in Black patients, and that each increases the risk of covid-related mortality. But even when we account for these health risks, we still find that Black patients die more often from covid-19 than their White counterparts.

Our study reveals why: Black patients have higher covid-19 mortality because they go to different hospitals than White patients. It’s not that some hospitals give worse care to Black patients compared with White patients; it’s that some hospitals have worse outcomes for both Black and White patients. And Black patients disproportionately go to the hospitals where the outcomes are worse for all.

Many forces combine to create this situation, but the common thread is racism. Decades of racial residential segregation have concentrated Black people in some areas and White people in others. Redlining, which limited mortgages in Black neighborhoods during the last century, reinforced and worsened residential segregation. Inequities in school funding, which is largely based on property taxes and other local resources, amplify the effects of this segregation. The result is economic deprivation and lack of upward mobility in racially segregated Black neighborhoods that persist to this day.

We see these effects in health care, too. Poor neighborhoods have proportionately more people who are uninsured or insured by Medicaid, which has payment rates that are often too low to cover the costs of care. People tend to seek health care near home. As a result, hospitals that are located in poorer neighborhoods have less to work with, and often lack the resources needed to provide optimal health care. In effect, doctors and hospitals in the United States are paid less to take care of Black patients than they are paid to take care of White patients. When we talk about structural racism in health care, this is part of what we mean.

These structures are deep, but there are ways to undermine them. When we expanded health insurance to uninsured Americans through the Affordable Care Act, we took an important step toward health equity. President Biden’s proposal to shore up the ACA and extend affordable coverage to more people would be another important step.

But more is needed. Medicaid, upon which a lot of the ACA is built, underpays hospitals compared with Medicare and commercial insurance. Hospitals that see a disproportionate number of Black patients also rely heavily on Medicaid, leaving them strapped for cash with little to invest in quality, patient care and social needs. Increasing Medicaid payment levels to Medicare levels would help address this structural inequity.

We should increase our investment in the health-care safety net, which relies heavily on hospitals. Hospitals receive partial support through supplemental payments for uncompensated care to uninsured individuals. These payments are essential to keep these hospitals afloat, but they are not large enough or targeted well enough to alleviate the financial burden under which these hospitals operate. As a result, safety-net hospitals still have worse financial performance and worse quality of care. They also struggle to meet the needs of the patients they serve.

Centuries of racism got us to this level of segregation and to these inequities in payment structure. Those enduring effects have played out in the setting of the covid-19 pandemic, and they are no longer a mystery. These effects are predictable. But they are not inevitable. We can stop the cycle of disadvantage that perpetuates these inequities by adopting policies that directly invest in these communities and their hospitals.

David A. Asch is a physician and director of the University of Pennsylvania’s Center for Health Care Innovation. Rachel M. Werner is a physician and executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Public Health and Population Health: Are They the Same Thing?

Public Health and Population Health: Are They the Same Thing?

NEJM Catalyst

Dave A. Chokshi, MD, MSc and Namita Seth Mohta, MD

Summary

The Commissioner of the New York City Department of Health and Mental Hygiene discusses the nexus between public health and health care delivery, and what New York City is doing to ensure care extends to Covid-19 patients once they leave the hospital. He stresses the importance of breaking down silos and earning patients’ trust through health care–community partnerships that provide more equitable care.

Namita Seth Mohta, MD, interviews Dave Chokshi, MD, MSc, the Commissioner of the New York City Department of Health and Mental Hygiene.

Namita Seth Mohta: This is Namita Seth Mohta for NEJM Catalyst. I’m speaking today with Dr. Dave Chokshi, the Commissioner of the New York City Department of Health and Mental Hygiene. In this role, the Commissioner is responsible for the health of the citizens of New York City. Prior to this, Dave was Chief Population Health Officer of NYC Health + Hospitals. He sees patients as an internist at Bellevue Hospital. Dave also serves on our NEJM Catalyst Innovations in Care Delivery editorial board. In all of these roles and in his prior experiences, including when he and I worked together at Brigham and Women’s Hospital, the Commissioner has been committed to improving the lives of the populations he serves.

We could discuss many topics today, but given his experience in both the provider and health system settings, as well as the government public health sectors, I wanted to focus on specific areas. First, Dave, I’d like to get your take on the overlap between public health and population health. Second, I look forward to discussing the opportunity and challenge of bringing innovations in public health and health care delivery. As you know, effective collaboration between the two will be especially critical as we address this next phase of the pandemic. We are delighted to have you joining us today.

Dave Chokshi: Thank you so much, Namita. I’m honored to be on the podcast.

Mohta: Let’s start with clarifying some concepts. Leaders who work in the public sector use the term public health, leaders who work in health systems use the term population health, and often I find that they’re referring to the same set of problems, challenges, and lists of potential solutions. From your perspective, how do you define public health and population health? What is the relationship between the two? What are the different levers and tools that organizations in these fields use to improve health?

Chokshi: My starting point on this is that I like to say that I’m a primary care doctor with a public health heart. What I mean by that is, the same things that drove me to pursue medicine, and that I think about every time I care for a patient, are very much the same things that I think about as the health commissioner for the city. Ultimately, whether we think of public health, population health, or health care delivery, the common thread that links all of those terms and, more importantly, all of those practices is the pursuit of health.

“Part of our common challenge, whether you’re a public health practitioner or a physician working in a health system, is thinking about all of the things that contribute to and generate health and making sure that what we are doing with respect to delivering services and changing the structures of society actually contributes to the health of the people whom we intend to serve.”

That is simple on its face, but it is something that has been very difficult to operationalize across those different sectors over the course of decades. Part of our common challenge, whether you’re a public health practitioner or a physician working in a health system, is thinking about all of the things that contribute to and generate health and making sure that what we are doing with respect to delivering services and changing the structures of society actually contributes to the health of the people whom we intend to serve.

Mohta: Building on that, some of our prior conversations have been about silos in our health care system, the silos of parts of the ecosystem that are pursuing that goal of health, but are oftentimes too isolated from each other. Can you share some thoughts and where you see the biggest gaps in areas of opportunity when it comes to bridging these silos? More proximally, how has Covid-19 affected your perspective on this?

Chokshi: To build on the first question that you asked, even though we strive to have a deep and abiding link between public health and health care delivery, that hasn’t always been the case. That’s the first silo that I would point to. Covid-19 has really brought this into stark relief: for example, the effectiveness of social distancing translates directly into the number of sick patients who end up in the ED and ICUs. What has always been true with respect to the policy or environmental approaches that often undergird what we think of as traditional public health, and how that translates into when people get sick enough to require health care, it’s something where the connection between those things has become much more tangible and visceral — both for people like us who have been steeped in the health systems for our entire careers, but, perhaps more importantly, for the general public as well, who have now understood that there is this link between what we do in the realm of public health and how that connects to what ends up happening in clinics and hospitals.

I think that’s a real opportunity, even though, of course, the last [several] months have been filled with so much tragedy with respect to understanding the limitations of our pandemic response, our preparedness in many ways as a country. One of the things that I hope we will be able to draw from and move forward with over the coming years is this idea that there is that nexus between public health and health care delivery. It’s something that we need to continue building on, tearing down the walls between those two worlds so that we can achieve that common cause of producing health.

The other thing that I would say on this point about silos is that, particularly when I look at it from the vantage point of someone who’s more thinking about health care delivery, the silo that always struck me the most, even before my own clinical training, was how physical health, behavioral health, and what we can think of as social health are all linked. You think about a given patient whom you’ve taken care of, and there are so many ways in which you can draw the connections between someone’s social circumstances, the risk factors that predispose them to, let’s say, alcohol use disorder, and how that affects the physical health of someone, whether it’s esophageal varices or liver disease. All of these things are packaged in an individual whom we take care of. Yet, in the way that we deliver those services, it’s too often separate, which causes problems both for people, for the whole person whom we intend to care for, but also for the systems that we’re trying to build around that care.

Mohta: I completely agree with you, and I would add to that the clinicians and care team who are trying to take care of that person in that system with a lot of challenges and limitations. To build on that, how could we take this physical health, behavioral health, and social health complexity and harness the power of this nexus between the health system and the public health system to make some improvements? What’s on your wish list of how we could leverage that nexus and that tangible individual connection that you mentioned to make progress on this complex issue?

“It starts with the health care system, realizing that our role in that is relatively limited. It’s one where we provide resources and where we are essentially the referral mechanism rather than anything beyond that. That allowed us to make sure that those community-based organizations were the ones that were both the trusted institutions delivering the service in particular neighborhoods, but also benefited from the resources that we were able to bring to bear.”

Chokshi: The way that I think about this is that it really needs to be rooted in humility. It needs to be rooted in this idea even though we may have this renewed interest in thinking about the social factors that underlie health, or we want to reach out to build specific collaborations between a local health department and a local health system. The idea that we embark upon that journey with humility, particularly from the side of health care delivery, feels fundamentally important to me.

The reason is that if you start with humility, it allows you to see that there have been people who have been working at those very same issues for decades. Whether it’s someone who has started a community-based organization to address food insecurity or has been thinking about whom we have recently termed “high utilizers” from the perspective of addressing their homelessness, there are so many latent natural resources that exist in our world that require a reflex to partnership. I found in my experience that just that simple step of taking a beat and saying, before we build something new, before we generate an investment in what we think of as an innovative program, let’s stop and understand the ecosystem in which our patients are already living. Let’s stop and think about the people who are better equipped than we are to support the people whom we intend to serve. I found that building those partnerships from that starting point allows us to be not just more tangible about our work, but also more effective.

Mohta: Can you share some specific examples of these partnerships and this approach of being rooted in humility from when you were at NYC Health + Hospitals, helping to lead the pandemic response, and then more recently as Commissioner?

Chokshi: Sure. One of the things that I think about a lot is at the height of the [first] surge in New York City back in March and April, we were, of course, as a city advising people to stay at home as much as possible. Unfortunately, for people who are living on the margins, for whom hunger and access to food were tenuous even when they weren’t in a pandemic, this caused very significant issues with respect to food insecurity. That reflex to partnership allowed us to work with the food banks, the community-based organizations that had been serving specific neighborhoods in New York City for many years with respect to providing access to nutritious food. What we were able to do is provide an infusion of resources as well as some direct connections, for example, after hospital discharge, which we know is such a challenging period in terms of recovery for people, and connect people up with those services.

But it starts with the health care system, realizing that our role in that is relatively limited. It’s one where we provide resources and where we are essentially the referral mechanism rather than anything beyond that. That allowed us to make sure that those community-based organizations were the ones that were both the trusted institutions delivering the service in particular neighborhoods, but also benefited from the resources that we were able to bring to bear.

“One of the things that I hope we will be able to draw from and move forward with over the coming years is this idea that there is that nexus between public health and health care delivery. It’s something that we need to continue building on, tearing down the walls between those two worlds so that we can achieve that common cause of producing health.”

In terms of the work that we’re doing more recently, we have thought a lot about how fundamental this idea of trust is for everything that we’re doing, whether it’s trying to ensure that our public health guidance is followed around physical distancing and wearing masks or getting tested, to planning and preparing for vaccination, particularly given some of the historical and, in many cases justified, distrust that exists in many of the communities that we hope to serve. We have really tried to center this idea that trust is an essential ingredient for turning a vaccine into a vaccination, which again means that maybe the right way to move forward is for us as messengers of government, as messengers representing health professionals, to take a step back in some instances and allow community leaders, faith leaders, people who look like and otherwise represent the people whom we are reaching out to, to be the ones who are delivering the messages that we need.

Mohta: How can [this approach] be helpful as we think about accelerating our efforts to provide more equitable care to all of the communities that we serve?

Chokshi: This is another area that I hope will be a lasting lesson [from] the Covid-19 pandemic. What I think of is the idea that health equity is not a sideshow; it’s not something that we need to do along with whatever the main event is in public health or health care. It is the main event. Health equity is what we have to solve if we’re actually delivering on that mission of improving health. All we have to do is look at the stark and dismaying outcomes with respect to deaths and hospitalizations among Black and Brown communities in the United States to realize that that is a core part of our job.

We have tried to do this in several ways at the New York City Department of Health and Mental Hygiene. Our core values are science, equity, and compassion. Elevating equity to one of the fundamental things that we focus on has helped us ensure that it’s baked into all of our work rather than being seen as a parallel path. I appointed the first-ever Chief Equity Officer, Dr. Torian Easterling, when I took the helm here as Commissioner and charged him with making sure that we both turned the spotlight inward and understand how it is that we need to think about equity within our own organization, but then link that up to our external equity efforts as well.

The final piece is what we’ve talked about a little bit already, which is making sure that when we think about equity, it’s not just about focusing on the data around disparities, but answering the “so what” question. How do we get to that point of community engagement, whether it’s around Covid-19 testing or around a Covid-19 vaccine, so that we are having the sometimes-difficult but honest conversations about how to be worthy of the trust of those communities? That is central to accomplishing our equity goals.

Mohta: First of all, thank you for that, Dave, and for your leadership in this critically important, fundamental way, of changing the way that we think about caring for patients and their communities. One last question: What are the one or two advances in health care delivery and public health that you are most optimistic about today?

“Health equity is not a sideshow; it’s not something that we need to do along with whatever the main event is in public health or health care. It is the main event. Health equity is what we have to solve if we’re actually delivering on that mission of improving health.”

Chokshi: I look at the amazing progress that has been made with the development of the mRNA vaccines for Covid-19 in astounding record time. We’ve almost taken it for granted as we’re seeing the news emerge. But I’m so struck by what we’re seeing with respect to the pace of science and how it can be brought to bear when there is this societal will to commit to advancement in that way. It reminds me also of what I saw back in March and April, when, even though we had been working for a year on building our telehealth infrastructure, literally overnight at NYC Health + Hospitals, because we were in the stay-at-home phase of the surge, we shifted to hundreds of thousands of encounters, now millions of encounters, to telehealth within days. I also remember walking through my hospital, Bellevue Hospital, and within a matter of hours an endoscopy suite was turned into a fully functional medical ICU, taking care of patients who were intubated and struggling with critical illness from Covid-19. All of these experiences have been seared in my memory, both as tragedy in many ways, but also as a testament to what can change when that will is there.

My great hope from the public health perspective is that we not forget that, and we make sure that when we are on the other side of this pandemic, we bring that same will to bear in terms of what we need to do to support and invest in public health. I’m talking about sustained investment over the long term and not just during an emergency, to make sure that we learn the lessons of how important it is to invest in prevention, to shore up our public health surveillance systems, to create these links that we’ve talked about across sectors that advance health and that take the opportunity that we’ll have through economic recovery to make sure that public health is central to it, because we will have learned how central public health is to the economy through this this very difficult experience that we’re all going through. So that’s my big hope, having seen what is possible over these last few months when smart, committed individuals band together, that we take that same volition and turn it into something that is much more durable and long-lasting.

Mohta: Commissioner, thank you so much for speaking with NEJM Catalyst today.

Chokshi: Thank you for having me.

'Safety net' hospitals join forces to raise voice in Albany. Here's what they want to do.

'Safety net' hospitals join forces to raise voice in Albany. Here's what they want to do.

POLITICO

Shannon Young

Several New York City “safety net” hospitals have combined forces to enhance their lobbying power in Albany as they seek a boost in state funding and larger structural overhauls to help secure their long-term survival.

The newly formed New York Safety Net Hospital Coalition, which represents nine facilities that serve a large percentage of Medicaid patients in low-income and minority communities, is pressing Gov. Kathy Hochul and state lawmakers to address the “longstanding structural inequities” in how they are paid.

They are also advocating for the state to put aside funding for overdue building repairs, equipment purchases and other capital investments.

Failure to do so, the coalition warns, could lead some of the hospitals to close their doors and put others on the brink of collapse — further exacerbating the longstanding health inequities in communities hit hardest by the Covid pandemic.

“We came together because we wanted to collectively make the case that the two-tier system of health care that exists in the state of New York has to stop,” said Ramon Rodriguez, the president and CEO of Wyckoff Heights Medical Center. “We built the coalition to have a voice. And people who are on the coalition are committed to serving the communities they’re in and essentially saying, ‘You have to have local health care access.’”

The coalition includes St. Barnabas Hospital, Brooklyn Hospital Center, Brookdale Hospital Medical Center, Interfaith Medical Center, Maimonides Medical Center, Jamaica Hospital Medical Center, Flushing Hospital Medical Center, St. John’s Episcopal and Wyckoff Heights Medical Center.

What the new group wants

The group lauded Hochul for including measures in her budget for the fiscal year that starts April 1 to help safety nets, such as the proposed $2.8 billion in payments to support “urgent operating needs.”

But members have argued the governor’s budget proposals — including the payments which would be doled out over four years (or $700 million annually spread across 18 hospitals with Medicaid volumes at 36 percent or greater in their patient mix) — do not go far enough.

The coalition has estimated that more than $1.5 billion is needed across the nine member hospitals in the coming fiscal year to move them away from “crisis cash-management” — or about $1.4 billion after the $128 million in projected "Disproportionate Share Hospital" payments they’re slated to receive.

But even with the state’s expected allocation of $987.6 million for coalition hospitals — and members advocating for $125 million in additional "Vital Access Provider Assurance Program" funds — the coalition estimated that a nearly $300 million budget gap would remain for the nine facilities to achieve a 1.7 percent operating margin, the average in New York.

As such, a coalition spokesperson told POLITICO, it is requesting that the state allocate an additional $292.2 million for member facilities.

“We’re grateful that there is some incremental increase in the funding from what we have been receiving, but it’s not enough,” said LaRay Brown, the CEO of One Brooklyn Health, which comprises Brookdale Hospital Medical Center and Interfaith Medical Center, among other facilities.

“It’s not enough for us to get beyond paying some vendors this week and others next week; it’s not enough to get us beyond just making payroll and maybe having less than a handful of days’ cash.”

There was no immediate comment from the governor's office on the group's requests.

Seeking further reforms

Beyond a cash influx, the coalition hopes to work with lawmakers, unions and others on a budget proposal next year to overhaul the safety net’s funding structure, including the Medicaid reimbursement rate — which currently pays about 67 cents on the dollar for hospital care in New York.

 The nine coalition hospitals serve 45 percent or more Medicaid and uninsured patients. That payer mix, members argued, puts their facilities at an operating loss for nearly all services and makes it hard to invest in things like equipment — a problem not equally felt by hospitals that serve mostly patients with private health insurance.

The coalition noted that the average commercial rates in Manhattan and New York City, “as a whole, are up to seven times higher than the average commercial and Medicaid managed care rates received by [its member] hospitals.”

The nine hospitals have asked state lawmakers to commit to “structural reimbursement reform,” by increasing Medicaid rates so they better reflect the cost of care — not just restoring cuts implemented in recent years, as proposed in the executive budget. The current rate, they’ve argued, has remained stagnant for more than a decade and applies to all providers regardless of their financial position or payer source.

The coalition, however, has lauded the executive budget’s proposed $1.6 billion to finance capital improvements for financially distressed hospitals and other health care providers, calling it “essential to reverse the current two-tier health system.”

“There’s only so much you can do if you’re not sure what your future is going to be,” said David Perlstein, the president and CEO of the Bronx-based SBH Health System, which operates St. Barnabas. “If I get fully funded, and I know I’m going to be fully funded for the next five years, I can plan, I can build, I can even borrow money."

Rodriguez, who said he’s spent decades working in or around New York’s state government, said Hochul is the first governor in his memory to specifically mention safety net hospitals in her budget priorities. He said he’s “optimistic mostly because of the governor.”

Brown agreed that between the state’s current financial situation, new leadership and focus on health inequities — a key priority for Health Commissioner Mary Bassett — the “ingredients are there for us as a coalition to have some success.”

“I think we’re close,” Perlstein added. “I am cautiously optimistic, and maybe a little more. But this is the first step: to make sure there’s equity. And the next step is to make sure that equity is carried on for eternity.”