I recently attended part of a day-long brainstorm session put on by 10.10.10. They bring a bunch of smart and entrepreneurial people into one room, pose ten “wicked” problems, and give them ten days to design new initiatives or business ventures that can tackle them. When I arrived partway into the event, I was assigned to the group working on the issue of health disparities in clinical settings. The brainstorming was rapid fire—who are the players? What’s the history of the issue? What are the constraints? What are the connected problems that have to be solved in order to make progress on this issue? We talked about institutional racism, the design of health care and coverage systems, and the social factors that influence a person’s health. Just as we were feeling completely overwhelmed at how intractable this problem is, lunch arrived. As I stood in line at the buffet with one of my fellow group members, he remarked that what we needed was a business case for health equity.
Well, there is a business case for health equity, and it’s pretty bulletproof. One study calculated that from 2003-2006, the economic cost of premature death and health inequities for people of color was $1.24 billion. As if that number isn’t staggering enough, it 1) doesn’t include the cost of premature death and health inequities for women, LGBTQ people, people with disabilities, people living in rural areas, people who don’t speak English or weren’t born in the US, and others our system has harmed, 2) is based on data over a decade old, and 3) only includes direct costs to the system—not the indirect costs of lost productivity because sick people can’t do their best work and dead people can’t pay taxes (adding those in puts us in the trillions). In other words, if our system is keeping people from achieving their best health, we all suffer the financial consequences, and they’re massive.
However, the business case for health equity largely exists at the highest level possible in the US health care system. Where are the incentives (besides, you know, doing the right thing) for hospitals, clinics, providers, and others that hold power in our health care system to change their business practices to reduce health disparities? It’s not cheap—where does the money to pay for it come from? And it’s not easy—how do you rebuild the plane while you’re flying it? If a hospital wanted to truly reduce health disparities in its patient population as much as possible, it would need to start prescribing housing, food, transportation, and other goods required to live a healthy life. And the insurance companies their patients were enrolled in would need to pay for those prescriptions. The culture of the hospital would need to shift dramatically, with all staff taking implicit bias and anti-racism training, and have those messages continually reinforced through the words and actions of leadership. Internal hiring and employee policies would need to be re-written with an equity lens, increasing diversity and cultural responsiveness, and the policies that affect patients would require an even more critical eye. The hospital would need to be an outspoken advocate for social, economic, and racial justice, helping shift the public narrative. There would be changes to clinical protocols, modifications to electronic health record systems, and a considerable reallocation of resources. And that’s far from an exhaustive list.
So we do still need to create a business case for health equity—we need to change the system to make sure there are financial incentives to reducing health disparities. Reducing or eliminating our reliance on a fee-for-service model to pay for health care services will be a key part of this. When hospitals’ and providers’ pay is based on the quantity of services they provide, that incentivizes more health care—not better health. The movement to change this is called payment reform, and there are ways that payment and health care delivery models can be designed to drive health equity. Marshall Chin, MD, outlines five additional ways for a health care system to contribute to health equity: collect outcomes data by race and income, track outcomes and quality measures that matter to patients, support the safety net, invest in primary and preventive care, and pilot new and promising approaches to health care payment and delivery.
Even if we can create a compelling business case for health equity, though, it won’t matter if we don’t change ourselves, too. If humans were solely motivated by financial incentives, the world would be a very different place. The (often unconscious) desire for power and social status drive otherwise well-intentioned people and organizations to make decisions that go against their financial interests, but sustain their privilege. And ultimately, we can only achieve health equity if we work together to solve the root causes of health inequities, like institutional racism and systemic oppression—and we’ll need a lot more than ten days to dig into those wicked problems.
This is our life’s work at Center for Health Progress. It’s why we’re building grassroots power to hold the health care system accountable for changing—applying pressure from the bottom up. It’s also why we’re influencing legislators and health system leaders to use their power to institute change at the top. This is hard work. And heart work. And we’re looking forward to partnering with you to do it.