Improving Health Equity Means Fixing Structural Barriers: Experts

Aine Cryts

January 25, 2022

Equitable healthcare treatment in the United States faces numerous barriers, from longstanding racial biases to overcoming economic hardships. But no matter the barriers, there are success stories in providing quality care for all patients of color.

The Hastings Center recently gathered experts from around the nation for its Health Equity Summit, a 2-day virtual event organized in collaboration with the American Association of Medical Colleges, the American Medical Association, the American Nurses Association, the American Hospital Association, and the American Board of Internal Medicine.

One of the sessions tackled the issue of finding and fixing structural barriers to equitable healthcare, providing three unique experiences facing three medically underserved communities.

Striving for Health Equity, Battling With Basic Necessities

When looking at healthcare inequity in the United States, one need look no further than what faces the American Indian population.

American Indians are twice as likely as White persons to have diabetes, according to the CDC. Food insecurity also affects approximately 1 in 4 American Indians, per Move for Hunger, a nonprofit that delivers food to food banks and pantries.

In addition to being more than four times more likely to be hospitalized with COVID-19, this population has a higher rate of COVID-19–related mortality at younger ages than non-Latino White persons, per the Indian Health Service (IHS). IHS provides services to 2.2 million of the country's 3.7 million American Indians and Alaska Natives.

Dr Tom Sequist

Tom Sequist, MD, PhD, chief medical officer at Mass General Brigham, adds that one third of American Indians in tribal communities also lack access to indoor plumbing and electricity and are often without cell phone or broadband access. As a result, improving health outcomes for American Indians is challenging, said Sequist.

"You cannot prescribe treatment regimens without knowledge about whether someone has electricity, because they may not have a refrigerator then to refrigerate the medications that you may be prescribing," he said.

To address these challenges, Sequist recommends the following:

  • Increase access to health insurance, especially Medicaid; when states increase access or pull back access to Medicaid, it "disproportionately impacts American Indians in terms of their access to care, particularly children," he said.

  • Address the 30% vacancy rate for clinicians in areas serving this population. He recommends training native youth and adults in the health professions.

  • Improve clinical data collection by more effective use of EHRs and population management tools. He observed that American Indians were initially classified as "other" at the start of the pandemic, which meant there was no visibility into the foothold the virus had taken among this population.

Vermont Prioritizes Access to COVID-19 Vaccines

Naming racism, using racism-explicit strategies, and developing frameworks that allow for the repair of harm caused by racism are three strategies that Michelle Morse, MD, MPH, advocates to address race-related health disparities. Morse is deputy commissioner for the Center for Health Equity and Community Wellness and chief medical officer at the New York City Department of Health and Mental Hygiene.

Dr Michelle Morse

At the Health Equity Summit, Morse highlighted efforts in Vermont to prioritize access to the COVID-19 vaccine for Black persons, indigenous persons, and other people of color communities. She said that 82% of Black Vermonters are vaccinated, which means it has one the highest vaccination rates among Black persons in the country.

Vermont gave access to the vaccine to residents who are Black, indigenous, and other people of color on April 1, 2021, whereas all residents 16 years of age and older had access on April 19, reported Kaiser Health News. People of color had been twice as likely as White persons to be hospitalized with COVID-19, per the Vermont Department of Health.

"That's a really important example of a race-explicit strategy because [the state wasn't] saying this was about some biological reason," said Morse. "They were saying that there was a history of harm from the biomedical system against people of color, and we know that there's going to be a lot of concerns around vaccine confidence, based on conversations they were having with these communities...the state wanted to make sure that [there weren't] racial inequities in vaccination rates."

Deploy Cultural Competency Training Among Behavioral Health Workers

Members of the Latinx and Filipino communities in California's Solano County who were enrolled in the state's Medicaid program were accessing behavioral health services at a far lower rate than White or Black beneficiaries, according to the California Health Care Foundation. That's despite the fact that these two groups represented nearly half (45%) of the county's population.

While behavioral health providers weren't capturing data about LGBTQ clients, the suspicion was that this group wasn't receiving adequate services, said Sergio Aguilar-Gaxiola, MD, PhD, director of the Center for Reducing Health Disparities at the University of California, Davis.

That's why he wanted to increase engagement with mental health services among these communities. The project, which was led by Aguilar-Gaxiola, involved providing training on culturally and linguistically appropriate services standards to behavioral health workers in California's Solano County, he said at the event.

The standards are designed to ensure that community members can access mental health services in the context of their ethnicity, race, language, and other personal characteristics, according to a report about the project.

After the training was provided to the county's behavioral health workers, Aguilar-Gaxiola said there was a marked increase in calls from patients seeking mental health services among the three target communities:

  • 1.5 times' increase among Latinos

  • 1.5 times' increase among Filipinos

  • sevenfold increase among members of the LGBTQ community

In addition, more than 90% of the county's behavioral health staff reported that they derived more meaning from their jobs as a result of the training; they also felt they were positively impacting people's lives and were inspired by the experience, said Aguilar-Gaxiola.

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