AHLA's Speaking of Health Law

Top Ten 2021: A Movement Toward Racial Equity in Health Outcomes

March 26, 2021 AHLA Podcasts
AHLA's Speaking of Health Law
Top Ten 2021: A Movement Toward Racial Equity in Health Outcomes
Show Notes Transcript

Based on AHLA’s annual Health Law Connections article, this special series brings together thought leaders from across the health law field to discuss the top ten issues of 2021. In the third episode, Annapoorani Bhat, PYA, speaks to Dawn Hunter, Network for Public Health Law, about current racial disparities in health care and how to promote racial equity in health outcomes. They discuss how health care disparities currently manifest in the United States, ways to classify and frame racial bias, legislative and policy actions that have impacted health outcomes for racial and ethnic minorities, and what hospitals and individuals can do to address this issue. Sponsored by PYA.

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Speaker 1:

The American Health Law Association is pleased to present this special series highlighting the top 10 issues of 2021, where we bring together thought leaders from across the health law field to discuss the major trends and developments of the year. Support for A H L A in this series is provided by P Y A , which helps clients find value in the complex challenges related to mergers and acquisitions, clinical integrations, regulatory compliance, business valuations, and fair market value assessments, and tax and assurance. For more information, visit pya pc.com .

Speaker 2:

Hello everyone. Welcome to another installment of a h l a's top 10 Issues in Health Law podcast series. I'm Anna Pba , a principal at p y a , and joining me today is Dawn Hunter, the deputy director with the southeastern region of the Network for public health law. Um, a little bit more about Dawn . Uh , prior to joining the network, Dawn served in a number of roles, including Director of Health Equity of the New Mexico Department of Health, where she managed the department's legislative and policy agenda among other responsibilities. So, good to speak with you today, Dawn. How

Speaker 3:

Are you? Good to be here. Great. Okay , thanks. Yeah.

Speaker 2:

Um, and I'm really excited to talk to you about this very important topic of racial equity in health outcomes. Uh , before we dive in, perhaps you could elaborate more about the Network for public health law to the listeners.

Speaker 3:

Yes. Um, so I am glad to be here today and, and share a little bit more with you on this topic. The Network for Public Health Law is a national network , um, of attorneys and staff. Um, and we do a number of things. We provide legal, technical assistance and consulting to state and local health departments, public health professionals and organizations. We conduct legal research and policy analysis, and we also offer trainings on law and policy as tools to protect and promote public health. Um, and then we have five regions across the us and as you heard, I'm based in the southeastern region.

Speaker 2:

Okay. Very good. Very good. So, Dawn , our topic today is really fuel for a very passionate discussion as there are , you know, very personal and emotional angle to this issue. For many Americans, racial inequity in health outcomes has been cited as one of the top 10 health law issues for 2021. I guess I will first ask you, how can we understand what healthcare disparity is?

Speaker 3:

Well being, you know, really simple, very simple description is a health disparity is a difference in health outcomes between populations. So a common des uh, example that you might hear right now when talking about like covid vaccine distribution is obesity. Um, some people in some communities have higher rates of obesity than other groups, but disparities are really more nuanced than that. Um, so some groups have been systematically disadvantaged and experienced greater barriers to health, and that could be due to their racial or ethnic group, gender income, education status, et cetera . And so these are things that are all factors and the differences that we see in health outcomes across populations.

Speaker 2:

Okay , very interesting. So can you elaborate perhaps to the listener how racially based healthcare disparities currently manifest in the US today? And perhaps, you know , you talked about this in, in an article that I had read and , you know, point to some useful ways to classify and, and frame , um, you know, racial bias so that we can sort of wrap our minds around it.

Speaker 3:

Yeah. So racial disparities or those disparities that we observe that affect racial and ethnic minorities to a greater extent than other populations , uh, you also might hear the word disproportionate used, and that means basically that a group , uh, is affected by something to a greater degree than what their share of the population would suggest. So an example of that in Florida is Hispanic or Latino people are 26% of the population. Um , but they make up 37% of the cases for covid. And so that tells us there's something wrong that this group is being impacted more significantly , um, than we might think based on what we know about, you know, the, the percentage of the population. Um, COVID also offers another great example, and I say great, I should probably say a not so great example that black and American Indian people have died at 1.4 times the rate of white people across the US due to covid. So those are, that's what a racial disparity in health outcome looks like. And another really good example that I did highlight in the article is maternal and child health outcomes. Um, three times as many black women and 2.4 times as many American Indian women in the US die due to pregnancy and related competent , uh, every related complications than white women. And I tell you why, this is always a fascinating topic to me because across a lot of health indicators, we see differences that are related to income and education. So if you make less money and you're less educated, you , you, you often have worse health outcomes. M maternal health is different in the sense that it doesn't matter what a woman's level of education is or what her income is, what kind of access to healthcare she has, black women in particular still experience significantly worse health outcomes , um, related to birth than , um, than white women and black.

Speaker 2:

I was thinking, you know, sorry to interrupt, but I was just thinking, I read , um, read in your article that black infants are significantly more likely to die when cared for by white doctors and more likely to survive when cared for by black doctors. Right . I mean, I was really surprised by that. It was quite an eye-opener. So maybe you can elaborate a little bit on that.

Speaker 3:

It is an eye-opener. I , I hope it's an eye-opener for, for anyone who's read the article or is listening to this In United States, black infants die at more than two times the rate of white infants. And the reason that infant mortality is important is that is a marker of population health. And it tells us a lot , a lot about the quality of care available in a community and to , um, pregnant women. And um, that study in particular is in I think the British Medical Journal. Uh , but it also tells us a lot about the fact that, you know, the lack of diversity in the workforce is a problem. And so , um, you know, having people to care for you who look like you, who understand your experiences and understand working with people who have your similar cultural , um, background and upbringing is a really important part of having good health outcomes.

Speaker 2:

Mm-hmm. <affirmative>. Yeah. And, and I I recall reading that you sort of classify racism as interpersonal, institutional and systemic mm-hmm. <affirmative>. Um , I thought that was very interesting. So could you elaborate a little bit about that?

Speaker 3:

Yeah, so interpersonal racism is what you might experience between two people , um, in an interaction within an individual. And what does that look like in a healthcare setting? So you might go to your doctor and your doctor doesn't ta your take your complaints about pain seriously. Or maybe they don't offer you the same care or care that you know has been offered to someone who has a similar condition to yours. Um, this actually often happens with pregnant women of color and is one of the things that contributes to the disparity we discussed, but it's not limited to that. And it's, you know, the , those interpersonal interactions with doctors who don't necessarily understand or relates to their patients of color , um, often creates problems. Then institutionally you have is really like, how is the institution itself managed? That institution could be a hospital, it could be a , a primary care clinic, whatever , um, level of institution it is. But you know , in the hospital, you know, what we just discussed is a good example. The lack of diversity in the workforce is a problem and the lack of culturally appropriate services for the community that's being served. And so at an institutional level, changes could be made to ensure that there are more people of color on staff to ensure that those services are available and that, and that staff are trained in how to provide culturally appropriate services. And then systemic is really about the laws and policies and the structures that limit our health and limit our access to healthcare in , you know, to healthcare . So a good example of that is health insurance. Everyone doesn't have access to health insurance here. And that is a systemic barrier to health, especially because, and we know that's a racial disparity and ethnic disparity because people are of color are more likely to fall in the group of uninsured.

Speaker 2:

Yeah. So , um, you know, I was kind of thinking about this has kind of happened overnight. There are lots of issues that must have happened in the past that has sort of fueled where we are today. So big picture, what are the significant legislative and policy actions that have impacted health outcomes for racial and ethnic minorities over the years? And what would you say, I just wanna add this sort of to the discussion. What would you say to those that believe that equal access to healthcare is also a personal responsibility?

Speaker 3:

Oh , well I have a lot to say about that. <laugh> <laugh> . Um, well I think there are some really core examples and I, I like that you mentioned history. Cause I think history is really important. So as I mentioned in the article, I'll highlight it here cuz it is so significant as title VII of the Civil Rights Act of 1964 , um, along with other civil rights legislation led to a significant reduction in infant mortality and improved conditions , um, for people of color. And that was followed around the same time with the Fair Labor Standards Act of 1966, an expansion of the minimum wage. And you might say, well, what does that have to do with anything? Well, it reduced pay inequities and we know that economic stability is a significant driver of health, but , uh, we also know that minimum wage increases also lead to reduced infant mortality. Interesting. There are some recent research that was just published on that topic. Um, and another big law of course was the Affordable Care Act and Medicaid expansion. As a result of that, there's some great research looking at how Medicaid expansion has improved health outcomes, has , uh, led to reduction in premature death and further reductions in infant mortality and expansion states. But it's important to note, as you heard, that infant mortality in particular is still a problem in the us . Uh , on the flip side of that, some bad things are lack of Medicaid expansion. So there are at least 12 states that have not , uh, that have not enacted , uh, Medicaid expansion. And in those states, 60% of the people who are uninsured are people of color. So that's what we call a systemic issue. Uh , another thing related to Medicaid is Medicaid work requirements. We have an example out of Arkansas, this was to your personal personal responsibility question that, you know, intending to encourage personal responsibility among Medicaid and rollies. But what we saw in Arkansas is that not only did it not increase employment, 18,000 people lost healthcare coverage. So we know that that is not the solution. Um, and I do think it's important to , to, to address the question of personal responsibility in the sense that, and public health messaging, one of the things we say is to focus on systems, conditions and places rather than people. So, and part of why we do that is we don't wanna reinforce the belief that your health outcome is due to only to your individual behaviors. And that's, and that's not uncommon with COVID and other kinds of diseases, cancers , um, obesity, diabetes, all things that, of course we know the impact of healthy eating and active lifestyles and all that, but it's more , it's more important to talk about the conditions and systems that limit our opportunities to have good health. So you might live in a food desert, you might live near an environmental hazard that causes pollution, that increases your risk to develop asthma or C O P D. You might not live in a community where you have a safe place to walk or public parks. Um, you might not have a healthcare provider in your neighborhood. And we know that's a particular issue , um, with mental health providers, especially in communities of color. And, you know, we can only make choices from, from the world of options available to us. So if your pool of options is not healthy , UN is unhealthy, it's not because of you, you know, it's unhealthy because of decisions that were made that affect the pool of options available. So , um, individual responsibilities is one part of how we maintain our health, but ultimately it's about the systems and conditions that create our opportunities for health. And that's where we have an opportunity to make change.

Speaker 2:

Yeah , I guess you're saying the environment needs to be conducive so that people can all make right choices or get the help they need. I mean, I often find despite feeling like, you know, I know how to look for information, even I can be lost, you know , trying to navigate the, the, you know, the puzzle of healthcare in the us . So I, I think I completely understand , uh, where you're coming with that.

Speaker 3:

Look at vaccines right now. I mean, if you live in a state where you have four different registration portals to get registered to get a covid vaccine, maybe you don't, you live in a community, you don't have access to internet , um, you have no way to sign up on these portals, you or you're relying on someone to call you from the health department or from a hospital that's distributing vaccines. These are all things , these aren't choices that you're making. This is the system deciding that it's going to be complicated to get people the vaccine. It doesn't have to be that way. And so, you know, me not being vaccinated is not because of my choice not to be vaccinated. Often, it's because even if it's available, there are so many barriers to, to getting yourself to a vaccine site and getting, being in one of the approved groups. I think that's just one of the, sorry if I , I sound animated about it because I think it's really frustrating , um, that we're, we're seeing that kind of play out in some states.

Speaker 2:

Yeah, I think that's a really relevant example that you've just given. So , um, I don't know whether to laugh or to cry about it, but I guess that's the state of affairs right now. What would you say is the role of hospitals and those who work in it, what can they do to impact this issue?

Speaker 3:

So one thing I'll highlight is, you know, I think hospitals , um, are members of communities and I like to talk about community because communities are powerful. We know that communities build , uh, social capital and we know that healthy communities , um, lead to healthy people individually. So in a role. And our hospitals are part of that, they're part of our framework, they're part of our community network. So one thing that hospital systems and health systems are doing right now is declaring racism, a public health crisis or committing to addressing systemic racism in some other way. Um, and what it means to declare racism of public health crisis is saying we're looking at it from a public health perspective, meaning it impacts large populations of people. And also recognizing that the type of intervention that is needed is at the systems level and at the policy level, that's what will really create change. And so a few examples of hospitals and health systems that are doing this are in Chicago, in Utah , um, Kaiser Permanente, the health anchor network, blue clo , blue Cross Blue Shield of Illinois, they're all, they've all made commitments and or have committed funding to racial equity initiatives. And this looks like a variety of things. Some of it's directed back toward the institution to, to look at its own policies and practices to make sure that it's equitable. And some of it's about directing assets to the community. So directing , um, investments to underserved communities , uh, looking at some of the things we've already talked about, like diversity in the workforce and on boards and in leadership. And another important one is using racial equity tools to assess policy programs. And what that means is basically , um, using a , a racial equity lens to look at , uh, whether or not your policies and programs are meeting the people who are most in need, whether they're being distributed equal , you know, in an equitable way, and whether or not they're actually engaging impacted community . So as I mentioned, you're a hospital, you're in a community, you know, how do you hear from your community members, not just the people who come and access your services, but um, in the community surrounding where you're established, what does that community need? How do you know if you're meeting their needs? And, and how are you accountable as, as a member of the community?

Speaker 2:

Yeah . Many ways that you can actually help. Um , right, right. So it's just, I think getting, coming together is sort of very important. Understanding the issue, of course, is the first step and then coming together as a community to resolve it, move, move in the right direction even.

Speaker 3:

Right.

Speaker 2:

So sort of maybe to wrap up our discussion today, you know, the events of the world today has demonstrated that empathy is really needed in both our professional roles and our personal lives. So as a takeaway, what is our individual call to action? What can our listeners, whether they are in-house attorneys, law firms, consultants, you know, individuals, what can we do to move the needle on this important issue?

Speaker 3:

Well, I wanna start with three kind of recommendations, and then I'll, and then I'll talk about a more general call to action. So the three recommendations , um, one is, which you mentioned, which is convene community conversations , um, as individuals and as part of systems that are ensuring the health of the people, you know, they serve, it's important to , uh, as again, engage a community. And so leading those or providing the space for those community conversations to happen, making sure , um, you, you often say, you know, if you hear about looking at whether something as equitable as one question is who's at the table? Do you have community members at your table? Um, and , uh, and how are you making sure that that happens? So the second thing I would recommend is partnership partner, partner partner , um, health departments, local nonprofits, community collaboratives are all , uh, partners who can be engaged because they're all also trying to ensure the health of the community. Um, especially when it comes to developing and implementing community health needs assessments, health equity plans, racial equity plans. There's real opportunity there , um, to kind of leverage those partnerships and , and amplify action by working together. And then the third thing I would say is investment. And there are two kind of, there are a couple different strategies, but one is place-based investment. Um, and there's a great resource for on this , um, from hospitals aligned for healthy communities. But it's looking at how you invest dollars into social, economic and environmental impacts. Basically the social determinants of health and, and the role of a hospital as a member and part of a community in helping to invest in community health. Um, the other, the other piece of that is leveraging comu community benefits requirements. And so , um, really more meaningful engagement of the community and that process to develop these , um, community health needs assessments, but then also to allow community members to make decisions and to help guide investments and to be accountable back to the community for whether or not those investments were successful, whether or not any changes need to be made. I'm a big advocate for continuous quality improvement. So , um, I would say that has to be part of the process. The last thing would be a more general call to action. And I, I say it starts with us, start with yourself and your own understanding of structural racism. Understand its effects in medicine. If you work in a hospital health system, I think you have a responsibility to understand , um, the disparities that exist among the people that you serve and why they exist. It will help, you know, make you , uh, and put you in a position to better serve. Um, I think as in , as attorneys and importantly as leaders, that we really have a responsibility to ensure that the law is being used as a tool to create a more equitable and just society. And that we can use it to challenge things when it isn't being used that way. And that we also have a responsibility to advise our clients, to advise companies, to invite our insti , advise our institutions on ways to advance a more e equitable culture and way of being. And so, you know, I think it's hard to say, you know, how can we make changes in institutions? We also have to make changes in the people internally and the people who are running those institutions. So understanding your own bi inherent biases, understanding your own approach to care, and being willing to confront it where it exists. You know, we have to start there and, and normalize these conversations. I know that talking about systemic racism , um, and, and racism in the healthcare system is difficult for some people. Um, but it's not going to get any easier. We have to keep talking about it and we have to normalize conversations about it and get past it as being this kind of divisive political issue. Um, to really say, you know, this is something that affects all of us. The structural barriers to health affects everyone's health. It just affects some of us more than others. So when we make changes in the system to make it more equitable, it ultimately leads us to a healthy community for everyone. So I'm probably going on, but I , I feel pretty passionately <laugh> about the topic. Oh ,

Speaker 2:

All of this is very interesting. You know , um, I, I know that we often refer to healthcare like education as a public good, which really means, you know, it doesn't serve just the individual who becomes healthy, but it also sort of reaches out and touches the lives of the community. A healthy person would mean more productive lives would mean, you know, more benefits to the, the family they live with or the community they live with. So if you're going to elevate the health of the racial minorities, it's going to elevate, it's sort of going to raise the, the boat altogether. Everybody's going to benefit from it. Uh , at least that's how I feel. So this was really fascinating conversation, Dawn . Um, do you have any closing remarks for, for our listeners?

Speaker 3:

I just wanted to say on that comment, David R. Williams out of Harvard said something very similar that the system that we have also places an upper limit on health for white people, right? So what you are saying is absolutely true. You know, a system that benefits some is gonna be , it's gonna benefit all of us, right? We can all benefit from better working conditions, from, from a better education system, from better transportation, from more equitable access to healthcare . So I , you know, I, I hope all of these messages, or at least some of them resonate with , um, with listeners of this podcast. And I would say, you know, I hope that you hear this, and then you take the opportunity to go out and look for additional resources that can help to shed light on, on some of the historical , um, injustices that have existed, that have led us to where we are today. Um, but also really to take time to look at strategies. I mean, there are, there are solutions out there and it's up to us to take initiative to, to lead and implement them.

Speaker 2:

Well, this has been fascinating, Dawn , and I'm so happy that we got a chance to connect on this issue. And thank you so much for your time and your insights. Um, I'm sure our listeners are gonna be very excited to listen to this podcast. Thank you.

Speaker 3:

Thank you so much for the opportunity to be here today. This was, this was a fun chat.