Our Healthcare System is Racist. What Next?
The Problem
Shalon Irving was an epidemiologist at the Centers for Disease Control and Prevention. Shalon had earned two master’s degrees and a dual-subject Ph.D. She had access to a top-rated health system and excellent health insurance. She was an advocate for eliminating health disparities, drawing on her education and her lived experience as a Black woman. Shalon had no reason to fear pregnancy as a highly educated, financially successful, medically informed woman in the United States with a strong family support network. Tragically, Shalon died just three weeks after her daughter’s birth. After reviewing her medical records, doctors identified several missed opportunities for the appropriate interventions. (Read more at ProPublica)
Unfortunately, Shalon’s story is not unique. Black and American Indian and Alaska Native (AIAN) women in the United States are 3X more likely to die from maternal complications than white women [2].
This is racism in the United States in 2023.
The Kaiser Family Foundation identifies six drivers of health disparities, all underpinned by racism and discrimination: economic stability, neighborhood and physical environment, education, food, community and social context, and the U.S. healthcare system.
It may be tempting to attribute disparate health outcomes to social and economic factors. However, doing so removes accountability from healthcare system. When controlling for social and economic factors, Black women still experience inequitable health outcomes relative to white women.
Among women who completed college education or higher, Black women are 5.2 times more likely to die from pregnancy-related issues than white women [3]. In fact, a 2016 study concluded that Black college-educated women were even more likely to experience pregnancy or childbirth complications than white women who did not graduate from high school [1].
Let’s play this out in a familiar context. Two friends graduate from Kellogg and go into consulting in New York City. One is a Black woman, and one is a white woman.
They live in the same Upper West Side apartment building.
They both have supportive life partners and a strong community of friends and family.
They both become pregnant at age 32 and immediately begin receiving care from the best health system in New York City.
Even with the same education, income, location, support system, and access to care, the Black woman is 5X more likely to die from pregnancy-related causes than the white woman [3]. This is racism in healthcare. And it’s happening to our friends, colleagues, family members, and other people in our communities.
“I’ve definitely experienced racism in healthcare. From my pain not being believed or addressed in a timely way to witnessing family members dismissed with poor bedside manner,” shared a 27-year-old Black woman at Kellogg. “It’s particularly interesting as I have several family members who are doctors. There have been many occasions when interacting with a PCP, surgeon, or other specialist when I have not been listened to or given the time of day as an adult until involving my doctor family members as consults.”
Doctors take an oath to do no harm. They work tirelessly to save lives. Often, racism in healthcare is unintentional. But it’s still unacceptable. So, what next?
Current Efforts
Racism in healthcare is a widely acknowledged issue, especially in the wake of wildly disparate health impacts from Covid-19 on Black communities in the U.S. [4]. Current anti-racism efforts include workarounds by marginalized groups, private investment in start-ups addressing the issue, and unconscious bias training for providers.
People who are marginalized have come to expect and prepare for racism when they receive healthcare treatment. Some people try to find providers of the same race, which can be particularly challenging when a 2018 analysis found 56% of the physicians in the US are white and only 5% are Black [5]. Others bring their white partner or in-laws to prenatal visits [1].
Given limited access to physicians who can relate with the lived experiences of their marginalized patients, healthcare start-ups are addressing the need for culturally competent care. The rise of digital health solutions has created an opportunity to connect patients from across the U.S. with culturally competent providers. SameSky Health offers multi-cultural content to guide people through the U.S. healthcare system. Violet Health provides cultural competence credentialing and upskilling for healthcare providers.
States, health systems, and medical schools are also seeking ways to address racism in healthcare. A popular approach is to institute mandatory implicit bias training for providers. At least four states (California, Maryland, Michigan, and Washington) have implemented regulation that requires some health care professionals to complete implicit bias training [6]. The Mayo Clinic Alix School of Medicine includes unconscious bias training in each year of its curriculum [7]. While unconscious bias training is just one of many necessary anti-racist interventions, it is a step in the direction of health equity. So, what next?
Systems-level Change
While expanding awareness and creating point solutions represent important progress, systems-level change will be the ultimate driver of anti-racism in healthcare. In the near-term, financial incentives from payers will drive the data collection and accountability needed to address racism in healthcare at scale.
The Center for Medicare and Medicaid Innovation announced that organizations that plan to participate in a value-based care model will be required to share their health equity plan [8]. Several states are experimenting with Medicaid payment models that measure and reward health equity progress. Oregon and Washington have demonstrated the most success in the health equity realm, though both Medicaid programs experience challenges with collecting standardized, accurate data to inform performance measures [9].
Long-term, national policies to address healthcare racism will be needed to incentivize behavior change across all providers and health plans. The Centers for Medicare & Medicaid Services (CMS) included health equity as a key pillar in its 2022 strategic plan [10]. As part of the strategy, CMS recently announced a proposed rule that would incorporate health equity measures into star (quality) ratings for Medicare Advantage and Part D plans in 2027, based on data collected from 2024-2025 [11]. These expectations from a critical payer (the U.S. government) will drive investment in health equity data collection and systems changes to measurably improve health outcomes for all.
What next, for you?
Access to quality healthcare is a human right. Promoting health equity is on all of us, and we all have a role to play. Educating ourselves, using our social capital to push for anti-racist policies and systems, voting for people who actively support health equity policies, investing in businesses that serve marginalized groups, talking about the issues, listening to those who have experienced racism, and more. What are you going to do next?
Sources:
[1] ProPublica: “Nothing Protects Black Women From Dying in Pregnancy and Childbirth”
[2] Centers for Disease Control: “Maternal Mortality Rates in the United States, 2020”
[3] Kaiser Family Foundation: “Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them”
[4] Kaiser Family Foundation: “Racial Disparities in COVID-19: Key Findings from Available Data and Analysis”
[5] Association of American Medical Colleges: “Diversity in Medicine: Facts and Figures 2019”
[6] PEW Trusts: “With Implicit Bias Hurting Patients, Some States Train Doctors”
[7] Health Affairs: “Implicit Bias Curricula In Medical School: Student And Faculty Perspectives”
[8] Fierce Healthcare: “CMMI: Expect more value-based care payment models to require health equity plans”
[9] Health Affairs: To Advance Health Equity, Federal Policy Makers Should Build On Lessons From State Medicaid Experiments”
[10] Centers for Medicare & Medicaid Services: “Pillar: Health Equity”
[11] Fierce Healthcare: “CMS proposes new Medicare Advantage and Part D reforms on prior authorization, marketing”
Preview image by Lawrence Crayton on Unsplash
About the author
Allie Newell (she/her) is an MBA + MS Innovation candidate at Kellogg focused on equitable design, digital health, and innovation. Prior to Kellogg, she led teams focused on strategy development and execution, innovation, and organizational design for healthcare clients at Deloitte. Allie is passionate about using design to create a more equitable world - join the conversation on Twitter at @allie_newell_