Opinion | Three Tools to Address Health Equity

In Washington, D.C., where I live, an infant born in 2020 had an average life expectancy of 75.3 years. If you jump the border between the nation’s capital and Bethesda, Maryland, a well-heeled suburb just north of the District, life expectancy jumps to 88.3 years.

The trek from Bethesda to the Capitol is less than 10 miles, but if you are lucky enough to be born in the ‘burbs, you will live more than a decade longer, on average. The disparity is even greater when comparing the east and west sides of the capital city, with a difference in life expectancies of as much as 30 years.

Washington, D.C., is not alone. In Chicago; Buffalo, New York; Baltimore; New York City; New Orleans, and Columbus, Ohio there are 20-to-30-year differences in life expectancies between neighborhoods in the same city. This story is repeated across other cities in the U.S. too.

This isn’t just an urban problem. Significant life expectancy disparities exist across rural regions too, especially in the Deep South and Appalachia.

How is this possible? And why are we allowing this to happen?

Socio-political determinants contribute to these disparities, but we must dig deeper. It is true that if you are born in some parts of the nation’s capital and rural areas, you are more likely to have to deal with housing instability, food insecurity, transportation gaps, and education and economic disparities. What’s more, lower-income rural and urban communities are less likely to have the number of physicians, particularly specialists, to serve the community adequately.

Bridging the health equity gap will require a shift in incentives in the current healthcare financial system, which has often eroded access, picked winners and losers, and perpetuated biases. Ours is a system built on disease management instead of disease prevention, often financially rewarding those who manage illness more than those who prevent disease.

The system has also been built on remnants of a racist, classist, and sexist past, and we must recognize that those remnants still influence policy decisions today. We also must confront inaccurate and inflammatory political rhetoric, diversify communication channels, and emphasize the importance of private investment. And, of course, providers, payers, business leaders, and policymakers must take an active role in changing the system both on population and individual levels.

A daunting task? Absolutely, but it is a necessary endeavor. Here are three tools that will help us on this journey.

Data

There is a lot of talk about data-driven decision-making with population health and health equity. At the same time, there are disparate viewpoints on how to measure impact in this space.

Leveraging data to assess outcomes from various interventions, drugs, and devices is, and will be, increasingly important for reimbursement and investment. In my class at the University of North Carolina’s Kenan-Flagler Business School, we discuss using outcomes-based pricing and real-world evidence to drive what gets produced, used, and reimbursed. Understanding population-based outcomes — whether a product or service actually works — are critical for financial success and the health of a community.

Of course, we also must recognize that data can be biased so, yes, we must “audit” the data.

What does this look like in practice? When Ernst & Young partnered with a health data startup to better understand chronic kidney disease (CKD), it found Black CKD patients were more likely to be diagnosed in the later stages of the disease, mostly because regular care was sporadic or delayed. As Ernst & Young said, healthcare companies use this model to “tackle similar barriers specific to underserved patient populations and preventable chronic conditions. For life sciences companies, this data can enable more inclusive healthcare experiences and drive commercial excellence.”

Communication and Respect

I will say it: Doctors can be a judgmental bunch and at times are not the best at communicating with our patients. We are, after all, trained to take in information and make an assessment (or a judgment) and make those decisions quickly. But people of color, people who never graduated from high school or college, women, and other marginalized groups are more prone to feeling judged by their physicians.

When this happens, they are less likely to seek our care.

According to the Urban Institute’s December 2020 Well-Being and Basic Needs Survey, more than three-quarters of adults (75.9%) who felt judged by their healthcare providers reported such treatment disrupted their receipt of healthcare. That number includes 39% of patients who delayed care, 34.5% who looked for a new provider, 30.7% who did not get needed care at all, and 11.4% who did not follow doctor’s orders (with some respondents selecting more than one category).

Tools like the CDC’s Health Equity Guiding Principles for Inclusive Communication help healthcare providers come up with a language that treats all people with respect. Additionally, the Rural Health Information Hub advises providers to:

• Use person-first language
• Avoid using gender-specific terms
• Use plain language
• Avoid the use of stereotypes and generalizations to describe individuals or groups
• Be cognizant of words or phrases that “rank” and “prioritize” individuals or groups

Private-Sector Partnerships

Expanding government programs like Medicaid is obviously essential to addressing health equity, as is an influx of private philanthropy and investment.

But the private sector, beyond healthcare corporations, has a role to play to improving health. As the World Economic Forum has said, “every company is a healthcare company” and can invest to improve health outcomes and life expectancy in their communities. As a group of researchers wrote in Harvard Business Review last year, options include:

• Using HR teams to help employees better understand their healthcare plans and benefits and what option might work best for their circumstances
• Ensuring employer-sponsored health plans cover out-of-pocket expenditures that are too costly for low-income families, yet are proven to reduce health disparities
• Investing in benefits, including nutrition programs, for example, that are not traditionally considered part of medical coverage
• Expanding primary care and mental health access through virtual care and community partnerships

The journey toward health equity is a formidable challenge, requiring a fundamental shift in how we design, incentivize, and implement our healthcare system. With bold leadership, however, we can begin to dismantle the entrenched disparities that can shave years off a person’s life if they happen to be born in the wrong zip code.

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