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From the Editor Health Equity
Alan B. Cohen
Mar 27, 2023
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In the June issue of the Quarterly, I recounted how the Milbank Memorial Fund, publisher of The Milbank Quarterly, confronted its role in the infamous United States Public Health Service (USPHS) Syphilis Study at Tuskegee and Macon County Alabama, and embarked on a journey of introspection and discovery to document, understand, and learn from its past. The journey is a long one and continues with intensive work on diversity, equity, and inclusion to fulfill objectives contained in our Racial Equity Statement of Purpose.1 Our overall aim is to transform our organizational culture and increase the diversity of our staff, Board of Directors, state policy networks, authors, reviewers, and editorial advisors. In pursuing this work, we have learned that the terms “diversity,” “equity,” and “inclusion” (DEI) often are used in ways that conflate or mischaracterize their true meanings. In fact, DEI has become a catch-all phrase for all activities that deal with issues of race and ethnicity regardless of their purpose or intent.
Of the three terms, equity is the most central to the work of the Quarterly and the Fund. As a key element of population health and health care, equity dictates that individuals have equitable access to health care based on need, and that societal resources are allocated equitably among population subgroups, allowing historically disadvantaged individuals and communities to attain their full health potential.2 Equity can be realized only when major drivers of health (e.g., social, economic, and environmental factors) are effectively addressed and chief obstacles, most notably structural racism and discrimination, are favorably neutralized.
Diversity generally refers to broader representation by individuals whose race, ethnicity, gender, socioeconomic status or other personal characteristics have denied them access, participation or voice in the past. Diverse perspectives and lived experiences are vital to understanding the needs of marginalized groups and are critically important to efforts for promoting equity in health and health policy. Inclusion thus has become a watchword for increased involvement of underrepresented groups in health policy making, community health care planning, health care delivery, and population health research. A more diverse health care workforce would better meet the needs of these groups, and more inclusive clinical trials would likely yield more targeted research findings to help minimize long-standing disparities in access and health outcomes for these groups. Many Americans, particularly white Americans, only now are beginning to realize the value of greater diversity in all aspects of society, and it is increasingly clear that diversity and inclusion are intrinsic elements within the path leading to equity. The path forward is challenging and requires a combination of strong leadership, resolute political will, collaboration among diverse parties, and transformative strategies and policies.
Our journey toward health equity thus far has taught us several important lessons, some of which are now incorporated in the Fund’s core values.3 First, as a philanthropy and a scholarly journal, we need to reach out proactively to individuals and organizations with diverse perspectives and experiences that will help us achieve our equity goals in program development and publications. This may seem common-sensical, but all too often, organizations like ours have made declarations of intent only to fall short in their actions. Our organization is stronger when people with a range of identities, perspectives, and experiences are included in our work. Second, in addition to marshaling our current networks of policymakers and scholars to help us identify new partners and authors, we need to broaden those networks to include individuals and communities that can extend our reach and potential impact. Effective policies and programs emerge when individuals and groups with diverse views and backgrounds work collaboratively in a relationship of trust. Third, because the journey toward equity in health and health care is never-ending, we know that we must persist in viewing all that we do through an equity lens. We especially value opportunities that come from listening and continuous learning, both of which enhance our ability to develop effective programs and to attract equity-focused research. Dedicated pursuit of these values is essential to rising above past shortcomings.
In this issue of the Quarterly, readers will find an interesting array of original research articles and Perspectives, including two that touch upon health equity. In “Health Equity and the Dynamism of Structural Racism and Public Policy,” Courtnee Melton-Fant examines the dynamic relationship between structural racism and public policy, arguing that efforts to address the health effects of structural racism must account for the reinforcing nature of these systems. She asserts that politics and policy are critical to our ability to understand the persistence of racial health inequities as well as our ability to create interventions that can mitigate the effects of structural racism on health.
In the United States, jails annually incarcerate millions of people who have profound and expensive health care needs. However, resources allocated for jail health care are scarce, and this can result in treatment delays, limited access to care, lower-quality care, unnecessary use of emergency medical services, and limited services to support continuity of care upon release. In “Jail Health Care in the Southeastern United States from Entry to Release,” Jessica Carda-Auten and colleagues conducted in-depth interviews with personnel from 34 jails in five southeastern states in 2018-2019, and found that jails’ strategies for delivering health care were often influenced by scarce on-site resources. Some strategies (e.g., using detention officers to perform medical duties) raise serious questions about safety and effectiveness, as well as broader concerns about the adequacy of jail funding and the impact of contracting with private health care companies. The authors discuss potential policy solutions, such as alternative models for jail health care oversight and financing, and alternatives to incarceration, particularly for those with mental illness and substance use disorders.
In addition to these equity-focused items, the issue contains articles on the influence of social determinants of health on future health care costs, policies for trauma-informed care, state policies supporting family caregivers, policy challenges raised by emerging telehealth models, health centers and value-based payment models in the Medicaid program, regulatory stances toward commercial determinants of health, the Hospital-at-Home model as an alternative means of delivering acute care, and the history and adequacy of breast cancer screening guidelines.
The use of telehealth in the United States has expanded considerably during the COVID-19 pandemic. Current discussions regarding telehealth policy generally appear focused on synchronous video and audio telehealth visits delivered by traditional providers and have neglected the growing number of alternative telehealth offerings. These alternative offerings range from simply supporting traditional brick-and-mortar providers to telehealth-only companies that directly compete with them. In “How Emerging Telehealth Models Challenge Policymaking,” Mitchell Tang and colleagues describe policy challenges in terms of using the appropriate payment model, determining the payment amount, and ensuring the quality of care.
In “Hospital-at-Home: A Landscape Analysis and Policy Framework for Reimagining Acute Care,” Kushal Kadakia and colleagues describe a home-based alternative for acute care that expanded significantly under COVID-19 regulatory flexibilities. The post-pandemic policy agenda for Hospital-at-Home will require consideration of multi-stakeholder perspectives along with the challenges of developing consensus on program standards, clarifying caregiver issues, creating sustainable reimbursement mechanisms, and mitigating potential equity concerns. The authors outline several policy prescriptions, including creating a national surveillance system for quality and safety, elucidating legal standards for care in the home, and implementing payment reforms through value-based models.
The 2009 decision by the United States Preventive Services Task Force to not recommend routine mammography for women under 50 created an uproar in the medical community. The Task Force was criticized not only for a lack of transparency but also for its use of differing concepts of evidence. In “Why Was the United States Preventive Services Task Force’s 2009 Breast Cancer Screening Recommendation So Objectionable? A Historical Analysis,” Barron Lerner and Graham Curtiss-Rowlands explore the history of evidence-based medicine (EBM), particularly as it relates to the evaluation of mammography in breast cancer screening. They argue that there is a tendency of EBM experts to question and push back against the prevailing view that more screening is better and that all cases of disease can be detected and perhaps cured if you simply screen enough people. They advocate acknowledging the built-in biases of EBM, as well as EBM’s own benefits and harms, in order to help groups like the Task Force make important decisions needed to guide the health care system.
It is well known that social determinants of health (SDH) contribute importantly to health outcomes, but their value in predicting future health care costs among persons with similar past morbidity burden and costs is less well-documented. In “Social Determinants of Health Influence Future Health Care Costs in the Medicaid Cohort of the District of Columbia Study,” Melissa McCarthy and colleagues report on a prospective cohort study of nearly 9,000 Medicaid enrollees who presented at emergency departments in two District of Columbia hospitals in 2017-2018. The participants were primarily female (66%) and black (91%). The authors used SDH information measured at enrollment to categorize participants into 4 social risk classes of increasing severity, and used Medicaid claims data for a 2-year period (12 months pre- and post-study enrollment) to measure past and future morbidity burden. The authors found that SDH were statistically significant predictors of future morbidity burden and future costs of care, controlling for past morbidity burden and past costs. They conclude that further research is needed to determine whether current payment systems adequately account for differences in care needs among patients of high medical and social complexity.
As recognition of the epidemiology of trauma and its impact on individuals has grown, so has the development of trauma-informed care (TIC). However, the conceptualization and implementation of TIC has been less clear. In “Understanding the Conceptualization and Operationalization of Trauma-informed Care Within and Across Systems: A Critical Interpretive Synthesis,” Maria Bargeman and colleagues reviewed and analyzed the literature to generate a conceptual framework that defines trauma and depicts critical elements of vertical TIC (i.e., the bi-directional relationship between the trauma-affected individual and the service delivery system), and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized language. In their view, TIC requires clear and cohesive policies that address operational factors, such as clearly delineated roles of service providers, a protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration.
In the United States in 2020, approximately 26 million individuals provided unpaid care to a family member or friend. Although a handful of patchwork laws exist to aid family caregivers, systematic supports are limited. In the absence of federal supports, states have adopted policies to aid providers, but policies vary in availability and level of support provided. In “The Landscape of State Policies Supporting Family Caregivers as Aligned with the National Academy of Medicine Recommendations,” Katherine Miller and colleagues used publicly available data from multiple sources to analyze and rank state policies to support family caregivers. The authors found that, although the landscape of state policies supporting caregivers had improved over a 5-year period, few states were providing financial supports as recommended and that substantial gaps in support of caregivers persisted. They point out that policies supporting family caregivers will become more critical over time, as the reliance on family caregivers as essential providers of long-term care is only expected to grow as the population ages.
Health centers are essential access points to comprehensive primary care for almost 29 million Americans, of whom 47% are Medicaid enrollees. As efforts continue to advance value-based payment (VBP) methods in Medicaid programs, health centers are positioned to implement the population health management strategies necessary in VBP contracts. In “Health Centers and Value-Based Payment: A Framework for Health Center Payment Reform and Early Experiences in Medicaid VBP in Seven States,” Rachel Tobey and colleagues studied the levels of health center participation, types of VBP contracts, characteristics of health centers participating in VBP, and variations in state policy environments that influence VBP participation in the states of Oregon, Washington, California, Colorado, New York, Hawaii, and Kentucky. The authors observed substantial growth in VBP participation in these states from 2013 to 2017, and concluded that a multi-layer payment model is useful for implementing and monitoring VBP adoption among health centers. However, they caution that state policy, financial incentives from Medicaid agencies and Medicaid managed plans, and greater collaboration between Medicaid and health centers will be required to increase health center participation in VBP.
The scholarly debate over commercial determinants of health (CDoH) has focused largely on markets that harm health, such as tobacco. However, some markets that interface between commerce and health do not inherently harm health. In “Using Regulatory Stances to See All the Commercial Determinants of Health,” Alex Liber argues that regulatory policy toward these markets should be different in intent than regulatory policy for markets with negative health effects. He proposes using a regulatory stances framework to classify public health preferences for regulating specific markets related to CDoH, based on the intended effects of regulations on market size. Regulatory stances may range from prohibitionist to contractionist to permissive to expansionist to universalist. He asserts that this framework expands the conversation beyond negative determinants of health and provides a more complete view of the tools available to alter markets and improve health.
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
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