There’s a Way, but Is There a Will?

Scott C. Cook, PhD

When it comes to reducing disparities in health and health care, we actually know a lot about the solutions.

This point struck me during a Health Affairs event at the National Press Club in Washington, D.C. on June 6, during which I appeared among a number of panelists who shared research published in the June 2017 Equity issue.

As Health Affairs Editor-in-Chief Alan Weil put it that day, the question at hand is not just whether we view equity as a critical element of health care, but whether we understand the obligations of the health care sector in achieving this goal.

We now have decades of research documenting racial and ethnic disparities, as well as substantial literature on interventions that work. Reducing the gap is a matter of will — on the part of payers, providers, the government, and recipients of health care — all of us.

The providers are motivated.

We hear from our Finding Answers grantees that being able to see the data that reveal disparities can be distressing — but engaging in work to reduce those disparities and watching the numbers improve is incredibly motivating.

The payers are motivated.

Some business groups have endorsed pre-K as a worthwhile public investment to create an educated, healthy and productive workforce. Similarly, health plans that align incentives and leverage existing resources create a more compelling ROI case for business investment to address disparities and inequity.

Our Fairfax County grantee partner sees reducing disparities, while improving quality and reducing costs, as an opportunity — because patients suffering health and health care disparities today end up with higher-cost health problems tomorrow. Similarly, Healthfirst in New York City is motivated to screen and treat new mothers at their postpartum care visit for issues that could potentially mushroom into expensive problems later. In rural Oregon, Advantage Dental is both the provider and the payer, so it really behooves them to invest in community-based screening, prevention and low-complexity treatment upfront to avoid complex and expensive problems later.

As for the government? Well, the will of the people is divided.

As Paula Braveman of UCSF’s Center on Social Disparities in Health noted at the Health Affairs briefing, fairness and justice mean different things to different people, and phrases like “level the playing field" can ruffle the feathers of those who don’t favor a government role in redistribution of resources. As Braveman said, equity requires removing obstacles to health such as poverty, discrimination and their consequences, and “You can pursue these goals with different levels of energy and commitment.”

Most providers believe disparities are rooted in social determinants and limited access to health care but aren’t sure what they can do, said Joe Betancourt, whose Disparities Solution Center at Massachusetts General Hospital works to translate research into actionable solutions.

The tactics involve collecting data, monitoring and developing interventions — similar to other solutions to health care value, Betancourt said. If there is little progress in equity, it’s due to lack of leadership buy-in, organizational culture, execution and external policy context that holds people accountable — or in the alternative, “a set of carrots that drive people to more equitable care.”

So how do we create political will for pursuing health equity?

We have to continue to document disparities, understand what creates the disparities and what creates resilience, and invest in testing bold interventions in different settings, Braveman said. This is exactly what our Finding Answers grantees are doing.

And the interventions need sustainable funding streams, with a research agenda that is tied to win-wins between public, private and academic entities who coordinate and align their actions to reduce disparities, Betancourt said.

Other panelists suggested that the will might just come from shared burden and opportunity.

As panelist Steven Woolf, director of Virginia Commonwealth University’s Center on Society and Health pointed out, health care is not the only sector concerned about equity.  Education, employment, housing, criminal justice, and public safety all need to deal with root causes of disparities in order to move forward.

Julia Berenson of the New York Academy of Medicine’s Center for Health Innovation said her team has adopted Sir Michael Marmot’s mantra: “Do something. Do more. Do Better.” And as their scorecard of state policies to promote equity showed, there are states leading the way in areas from encouraging healthy behaviors (via cigarette tax) to expanding access to clinical care (Medicaid expansion) to addressing economic factors (increasing the minimum wage). Louisiana, the latest state to expand Medicaid, found a way to piggyback on existing programs for low-income populations in that state.

But perhaps nowhere was the question of will more apparent than in Harvard graduate student Joachim Hero’s population survey of people in 32 countries: while Americans are more aware of our country’s unmet health care needs, we’re also in the lower third of countries bothered by it. We must find a way to overcome partisan politics to make a broader case that can be compelling to the public.

And so it was encouraging to see the high quality of research being conducted on health disparities and opportunities for action. But possibilities are not enough. In a highly politicized climate, can we find common ground? Finding Answers is pursuing a focus on payment reform directly linked to health care delivery to reduce disparities, because this is one place where public will can reside.  


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