The American healthcare system spends almost double per capita what Germany, our nearest health expenditure peer, spends. Despite these investments, overall health status in the United States lags behind countries that spend less. Notably, studies continue to show clear disparities in health outcomes tied to maternal mortality, heart attack, stroke, cancer, diabetes, and asthma among people who are Black, brown, and low-income. These challenges are systemic; for example, people of color earn lower wages and disproportionately live in poverty. Poverty leads to dilapidated housing that’s associated with childhood lead poisoning—which afflicts Black children disproportionately—and a lack of access to open space that is linked to obesity. These same homes are often located in food deserts that lead to poor nutrition, and in areas subject to poor air quality. The same people who are subject to so many health stressors also are those most likely to receive lower-quality healthcare. How are we going to close the gaps in care and ensure health care investments drive better health outcomes? By advancing health equity in all that we do. Starting now.
Health equity means the same populations have the same opportunity to achieve good health, no matter their race/ethnicity, gender identity, sexual orientation, disability status, language, education, income level or other factors. And it requires more than just data that illustrate where inequities persist. It also may require different levels of investment to close gaps in services and other determinants of health. That means we need to look at health inequities’ root causes, examine our systems, and bring in the everyday experiences of the people who are touched by these systems to help us ask the right questions and find the answers that will work. We need to measure and monitor the gaps to understand where the disparities are, what are they, who’s experiencing them, and are they growing? We also need to be more inclusive in our data collection and analyses. For example, in Minnesota, Abt is developing a dashboard to help policymakers monitor access to community-based services for people with disabilities—and disaggregate these data by geography, race and ethnicity, and preferred language. We’re taking this approach across sectors—from education to environment, health to housing—because we recognize the critical need for and power of integration across agencies, programs and data sets to improve services, outcomes and opportunities for all people.
Addressing Health Related Social Needs as a Root Cause
Along with Minnesota, many agencies, partners and communities are already hard at work. The Centers for Medicare & Medicaid Services (CMS) is testing innovative health programs that seek to connect the dots, address root causes of disparities, and potentially change systems and policies for the better.
Recognizing that wraparound services to address social needs are crucial to improving the health of low- and middle-income families, CMS launched the Accountable Health Communities (AHC) Model. AHC is intended to address the gap between clinical care and the social services that are necessary to support people’s health. Access to healthy foods, assistance with housing services or transportation are all examples of social needs that can influence a person’s ability to achieve good health. To that end, the program linked Medicare and Medicaid beneficiaries to relevant services through bridge organizations like hospitals, nonprofit organizations and public health agencies. As part of the evaluation team, Abt and partners found that challenges in connecting people to needed resources impeded progress, but identifying those gaps is an important first step.
Similarly, CMS’s Integrated Care for Kids (InCK) Model funds states and organizations that integrate behavioral, physical, and other health-related services for children. In our ongoing evaluation, we have identified some best practices, including:
- Programs were designed around their communities’ needs.
- Awardees developed new reporting systems to better share data between health and Core Child Services providers and with CMS.
What can we do today? Remember that communities’ needs and collaboration point the way forward. First, we need to include the most impacted communities from the start: in data collection, in policy drafting, and when we design solutions. Second, we need to understand and address the linkages between the various social determinants of health—which, as noted above, range from health to housing, and education to environment. With those data and insights, we can facilitate a dialog between service providers and communities to understand the needs, and how they can best be met, and that includes sharing data.
At Abt, we’re increasingly incorporating and enabling these approaches. In our evaluations of AHC and MOM, we included qualitative data from those most impacted—care recipients—alongside the quantitative data we collected. Similarly, in our evaluation of the benefits of recovery coaching for the Administration for Children and Families, we’re partnering with experts with lived experience to make study design and implementation decisions that are responsive and relevant to parents, families, and communities. The technical assistance we’re providing to the Health Resources and Services Administration’s National Health Service Corps includes developing resources to help care providers address local health disparities and patients’ social determinants of health.
This approach to incorporating equity informs Abt’s work across our portfolios. Our colleagues on the Climate, Energy, and Environment team are helping states collect data that explicitly identifies environmental justice concerns, disaggregating information to accurately—and specifically—identify the scope of inequitable environmental health impacts. Abt’s Housing team is evaluating guaranteed income programs by speaking directly with recipients to understand how they are using this no-strings-attached cash benefit to meet their households’ needs—without traditional restrictions from policymakers, who may be one step removed from beneficiaries’ challenges. We’re also helping to evaluate the health impacts families experience when using housing vouchers to move to public housing of their choosing.
Health equity is not just about the data or a policy. And it’s definitely not about checking boxes to meet healthcare’s diversity, equity, inclusion, and accessibility goals. To bring true equity to healthcare, to improve health outcomes for everyone, we have to synthesize all of the above … and more. It’s a circular and dynamic approach, and at its center are the people we’re here to serve. After centuries of historic and systemic racism, there is a lot of ground to cover, but the good news is the journey has finally begun.