How Can We Achieve Health Equity?

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In today's episode of The Fundamentals, we talk with Dr. John Ayanian, director of the U-M Institute for Healthcare Policy and Innovation. Dr. Ayanian's research explores underlying factors that contribute to persistent health disparities between minoritized groups and their white counterparts, as well as strategies for ending inequity in health care and improving overall health outcomes for everyone.

Transcript

Kelly Malcom:

Welcome to the Fundamentals, a podcast where we explore biomedical research here at Michigan Medicine. Research is fundamental to University of Michigan's mission to improve the world. On each episode, we'll meet the people behind the research, learn more about their fields and the fundamental questions they are trying to answer. I'm Kelly Malcom, a science writer and communication strategist for the University of Michigan Medical School. This season, we'll start by explaining a little bit of the history behind the questions our experts are asking and get a glimpse into the future of healthcare.

In 1965, Medicaid and Medicare were signed into law by President Lyndon Johnson. Medicaid in particular was designed to be a partnership between the federal and state governments to provide health insurance for those in need, including children, pregnant women, the elderly, and people with disabilities. Medicare offers care for adults over the age of 65. Over their 60-year history, these programs have provided a much-needed safety net for millions of Americans.

However, complicated eligibility criteria rules around what types of medical care are covered, and the fact that states can opt not to participate has led to uneven coverage for many of the people most in need depending on where they live. This is especially true for people in racial and ethnic minorities, groups who were actively discriminated against before and after the creation of these programs, for example, via segregated and underfunded hospitals.

In the Jim Crow South, Black people and other minoritized groups were more likely to be employed in low-wage jobs that provided no or inadequate health insurance. Yet because they worked, they were ineligible for Medicaid. The passage of the Affordable Care Act in 2010 expanded coverage to people younger than 65 who earned up to 138% of the federal poverty level which is a little over $43,000 for a family of four. States that adopted this Medicaid expansion saw more people receiving health insurance, yet many states, including those with the highest populations of Black and Latino residents, opted not to expand.

Differences in insurance coverage contribute to health disparities in the US; differences in health or healthcare that arise from social or economic inequities. However, even when insurance coverage and socioeconomic status are considered, health outcomes for minoritized groups lags behind those for white people. A report from the Institutes of Medicine of the National Academies entitled Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All, examines some of the factors that underlie persistent health disparities. Our guest, Dr. John Ayanian is an author on the report and is director of the U of M's Institute for Healthcare Policy and Innovation. Welcome to the show, Dr. Ayanian.

Dr. John Ayanian:

Thank you very much for inviting me to discuss this important topic with you.

Kelly Malcom:

When I'm thinking about health disparities, one of the first things that comes to mind is, "Oh, they're a product of people having differing levels of access to care." That's just my gut instinct. But I think the report, the Ending Unequal Treatment report hints that that's not the total picture. Can we talk about access first though? What is the connection between access to care and maybe some of the differences in health outcomes for different populations?

Dr. John Ayanian:

So access to care is a critical part of determining people's health outcomes. In the United States, we have a very fragmented and uneven health insurance system. So many people are covered by private insurance through their employers. Another large portion of lower income Americans are covered through Medicaid, which is a public insurance program, a partnership between the federal government and individual state governments. And then older adults in some chronically disabled individuals are covered through Medicare, which is a national public insurance program.

So because of all those different ways that we cover people, it's easy for people to fall through the cracks if they're not employed but live in a state that doesn't offer expanded Medicaid coverage or if they change jobs or if their employer changes insurance plans, they can find themselves struggling to get access to care and to pay for care. And that plays out differently in different communities, those historically minoritized groups.

So Black Americans, Hispanic Americans, some subgroups of Asian-Americans, and certainly American Indians and Alaska Natives are more likely to be uninsured or to have lower quality health insurance, what we call underinsured Americans where they have some coverage, but it doesn't pay generously for the care they need, and they can be left with large out-of-pocket costs.

So all those factors come together to make access to care very uneven. And if people don't have good access, they may not get timely preventive services or diagnosis and treatment for their acute or chronic medical conditions, and then they have worse self outcomes as a result.

Kelly Malcom:

I think most of our listeners would agree that the US healthcare system is broken on many levels. Why is there a disconnect between how much is spent on healthcare and the US and the health outcomes?

Dr. John Ayanian:

Well, we know that the US spends at least 50% more per person on healthcare than any other high-income country in the world. And despite that increased spending, we continue to have a very fragmented healthcare system. It's very uneven in quality and the resources that we provide in different communities and people's level of insurance coverage is very uneven. So with all that fragmentation, and we also under invest in good primary care. Most other countries devote much more of their healthcare spending to having a strong foundation of primary care and then supporting that with strong specialty care when needed.

In the United States, the primary care we do have can be quite good, but it's insufficient for the size of our population, and many people struggle to maintain primary care because of a shortage of primary care physicians and nurse practitioners, and physicians assistants who provide that care. And then finally, we under invest in prevention and public health. So when you put all those factors together, we tend to have higher rates of chronic disease, for example, higher rates of obesity in the United States than most other countries in the world.

One success story is we've greatly lowered our smoking rates in the United States over the past 40 years, and that has probably helped to improve health by reducing cancer and heart disease and strokes. But at the same time, we've had substantial increase in obesity. We've also had the opioid epidemic, many people dying of overdoses. And so when you put all those factors together, we actually end up spending a lot more on healthcare, but having shorter life expectancy and a greater burden of chronic disease and worse health outcomes, and that's not good for America. It reduces our longevity and our productivity, and the quality of life that Americans can achieve because of their health limitations.

Kelly Malcom:

So if we're improving access, let's say through the expansion of programs like Medicaid, does that have a positive effect on these health outcomes?

Dr. John Ayanian:

Yes. In fact, a team of us here at the University of Michigan have been working with the Michigan Department of Health and Human Services and our state Medicaid program over the past 10 years to understand what impact Medicaid expansion has had here in Michigan. So in 2014, the legislature and the governor agreed to expand Medicaid. Each state had an option whether to do that to include all adults up to 138% of the federal poverty level, which is about $16,000 a year back in 2014 when that decision was made for a single adult.

And with that expansion, what we've seen is that many of those adults newly enrolled in Medicaid, have reported better access to care, more likely to have a source of primary care and more likely to get important preventive services like cancer screening or screening for diabetes or high blood pressure. We know from the evaluation that they also report better physical health, better mental health, and actually better oral health as well because dental care was part of the expanded benefits under Medicaid.

Kelly Malcom:

Okay. All of that is really good news, but from the report, it seems like there are other factors. So even if you're holding constant for insurance coverage, that there are still health disparities. What are some of the reasons outlined in the report for those health disparities?

Dr. John Ayanian:

Medical care itself is very unevenly distributed in our country. Some communities have more ample supply of physicians and hospitals and treatment facilities like ambulatory surgery centers, and generally those services tend to be more available in more affluent communities, areas where people are more educated, have higher incomes, are more likely to be covered by health insurance because that's more profitable for the organizations providing care, to deliver care in those communities.

But the flip side is that lower income communities in urban centers in rural areas often don't have the same level of providers in their community, so that even if they want to seek care, there may be much smaller number of physicians and clinics, and hospitals that they can access, or they have to travel larger distances or wait longer for care. So that's one reason why we see these differences. There are other factors that the National Academies report pointed to, for example, language services.

For many people in the United States, they may have limited English proficiency. Now, the federal government has established standards that healthcare organizations should be providing interpreter services so that everyone can access care and speak to providers in the language that they're comfortable with. But that also is very uneven. I think some organizations do a very good job of providing interpreter services, but some communities have a much wider range of immigrant populations and languages represented in their community. And if people can't communicate with their providers through an interpreter, it becomes much harder for them to report their symptoms to discuss concerns they may have about treatments and to make informed decisions.

So that's another example where disparities can arise as our country becomes more diverse. The healthcare system needs to evolve to serve the needs of a more diverse population.

Kelly Malcom:

I know that you also mentioned it in the report, and this is you and the commission mentioned diversifying the workforce. Why would that be important?

Dr. John Ayanian:

Well, we want the healthcare workforce to reflect the diversity of the population in the United States, which has changed in recent decades and will continue to change. And what we know from some research that it's well established that some patients prefer to see a physician of a racial or ethnic group that's similar to their own that may speak their language if they are not fully proficient in English.

And it makes them more comfortable with healthcare, better able to communicate their needs. And they report being more satisfied with care, and in some situations actually getting better quality care as well. So I think we want people to have the opportunity to have a choice in providers. In the US healthcare system, we value choice for all Americans in being able to choose where they get their care and from whom. And this is just another way that we can encourage those options by having a more diverse workforce.

I'm a primary care physician, and when we practice with other clinicians with different backgrounds from our own, I think they help us understand the needs of patients and communities in different ways, and we learn from each other, and that's another benefit of having a more diverse workforce.

Kelly Malcom:

Is there anything we can do as we are training up the next generation of medical providers to maybe cut down on some of these patient-provider relationship effects?

Dr. John Ayanian:

The report talks about having a more diverse workforce that really requires us to take a long view and think about how do we improve elementary and secondary education so that students are prepared for careers in science and other fields related to medicine? How do we support students to have access to a college education and be prepared in college to then apply to medical school or other health professional schools? So I think that is one important step that requires the whole society and the education system broadly to help ensure that students from less advantaged backgrounds when they have the talents and the interest to pursue a career in a health profession, that they're supported to do that.

I think once students are in a health professional program, we have to expose them to the ways that patients in different communities may express their needs, understand the role of cultural and socioeconomic and environmental factors in determining people's health outcomes. We know that healthcare is only one small part may be estimated to be 20% of the factors that influence people's ultimate health outcomes, and it also has a lot to do with the community in which they live, the resources, the environment, the socioeconomic opportunities as well as individual health behaviors and encouraging people to live healthy lifestyles.

Kelly Malcom:

Do you have any other suggestions for reducing health disparities in promoting health equity? For instance, I know when I take my son to the pediatrician, we fill out a form that asks, "Do we have enough food to eat and do we have shelter?" Are there other things that go beyond just that doctors' visit that can help some of these things?

Dr. John Ayanian:

What you described is what we call screening for social determinants of health or health-related social needs issues like food security, housing security, transportation barriers, opportunities for people to feel safe in their neighborhoods and in their homes. And that's a relatively recent development that the healthcare organizations have begun asking those questions of patients. And it's asking by itself won't make anyone's health better. But what we're starting to do is try to connect and partner with community organizations and social service organizations.

So if we identify an individual or a family that is having trouble paying for food or maintaining stable housing, that we could connect them with community resources. And in fact, the Medicaid program is starting to support those efforts more actively because a lot of those health-related social needs are more common in lower income families or lower income communities. So that's an example where bridging the healthcare system with the social service system in the United States can help people to improve their health and identify needs that obviously are very important in addition to the medical care and the tests and treatments that they get in the healthcare system.

Kelly Malcom:

Okay. So if Medicaid and the expansion of Medicaid results in these positive outcomes, what are the barriers to just maybe making Medicaid for everyone? Why is there any resistance to doing that?

Dr. John Ayanian:

Well, we know even with the Medicaid expansion under the Affordable Care Act, back when it was launched in 2014 about half of the 50 states chose to expand Medicaid right away. And about another quarter have chosen to expand Medicaid over the past decade, sometimes in red states when voters in those states actually went to the ballot box and majorities around 60% of voters in a number of red states have pushed their state governments to expand Medicaid.

But we're still left with about 12 states that have not expanded Medicaid, including some fairly large states like Texas, Florida, Georgia. And in those states, the political will has not been there to expand Medicaid, in part because legislators or governors may be concerned about the cost of Medicaid. But in fact, the federal government is covering 90% of that cost. And we know from work that we've done here in Michigan that those federal dollars more than cover any of the state costs in terms of increased economic activity and additional tax revenue for the state.

So it's a good deal for states. So it's hard to explain why some states have chosen not to expand Medicaid, but it's in states that historically have less generous public benefit programs where there's concerns about structural racism. And many of these are states in the deep south that really have limited benefits and disproportionately affects Black Americans in those states, and in some cases Hispanic Americans as well.

Kelly Malcom:

One of the major points from the report is that we need to let people know that there are these inequities. How do we know that they exist? And then how can we measure if any improvement is made over time?

Dr. John Ayanian:

The most important step to know whether disparities and inequities exist and whether they're changing or improving, is to have strong data systems for monitoring. First of all, accurately people's self-reported race and ethnicity, their preferred language, those are important factors to understand when we then look at how healthcare differs. And we've made a fair amount of progress in the past 10 to 20 years in improving data systems to have accurate race and ethnicity and language data, but it's not consistent across the board.

So one of our committee's major recommendations is that the federal government set standards so that all healthcare databases have accurate race and ethnicity data, and it's enabling us to track health disparities over time more accurately and assess whether those disparities are getting worse, getting better, or not changing. And obviously, it's in all of our interests to have more equitable care in society because what we often find is when healthcare systems are improved to address inequities, all Americans benefit.

And so communities that raise the level of care for some of their most disadvantaged patients, for example, in trauma care or maternal and neonatal care, when those systems improve, it benefits everyone in the community, whether they're from those disadvantaged groups or not.

Kelly Malcom:

So I think there are probably already laws and guidelines in place that protect or should protect against some of these more outright discriminatory practices. How do we make sure that they're being followed? And what was the recommendation from the committee regarding those?

Dr. John Ayanian:

So our committee looked closely at the role of civil rights laws and regulations, which are already well established but not evenly enforced. And so one of our strongest recommendations was for the federal government to enforce those civil rights laws and regulations more consistently and that requires funding from Congress. It requires active engagement from the Office of Civil Rights within the federal government. But that's a tool that the federal government has that could be applied more evenly, and we believe would go a long way towards bringing healthcare organizations up to the standards that the federal government has already set.

Kelly Malcom:

So what is some of your advice for maybe researchers or students who might be listening to this who want to do something about this problem? What do you suggest they do to get involved?

Dr. John Ayanian:

Well, a first step would be to read our National Academies of Sciences Engineering and Medicine report on Ending Unequal Treatment. One of the roles of this report was to review all that's been studied and accomplished in the past 20 years since the original report titled Unequal Treatment was released by the National Academies back in 2003. So this report really contains a lot of the evidence that has been gathered in the past 20 years.

So that's an important start, I think, to be better informed because I think for students or researchers to contribute to this field, it's important to be well-informed about what's the work that's been done to date and what some of the challenges are that have not yet been resolved. I think community engagement is a particularly important part of this work and something that our committee emphasized that it's important to understand data at the state and national level, but to really understand how disparities and inequities play out.

It's important to talk to people in the communities that are affected by these disparities and to understand their lived experience and some of the barriers they face as well as to understand some of the resilience and the successes that they've experienced when care has improved, or partnerships between healthcare organizations and community organizations have led to better health.

There are examples of that in our report. Part of the problem though is even when we identified successful interventions, oftentimes the funding and the willpower has not been there to disseminate them more widely. So we've got examples of successful interventions and programs to reduce health disparities, but in general, they have not been widely adopted. And so there's a translation that needs to happen, and there's a role for policy, but there's also a role for researchers to study how to disseminate that work for students to get involved in working with some of the organizations that can expand those programs. And then for healthcare organizations to be bringing those successful interventions into their own communities.

Kelly Malcom:

If someone feels like they're not receiving the best care that they could get, what do you do? What's your recourse?

Dr. John Ayanian:

If a patient or family feels like they're not getting the care that they think they deserve or need, I think the first step is to talk to their healthcare team. I think most healthcare professionals and their teams want to deliver good care. Sometimes there can be honest misunderstandings or gaps in communication. And if families and individuals are able to advocate for their needs, I think that's... And explain their needs. That's an important first step. Most healthcare organizations, particularly hospitals, have patient relations teams where if patients feel like they do have an unresolved concern with their provider, particularly that may relate to health inequity, they can bring that to the patient relations team, and they will often help to mediate between the providers and the patients to try and resolve misunderstandings.

And the insurers also have a role to play. So if people feel they're not getting the care they need from insurers, excuse me, from their providers, they can talk to their insurers, whether that's a public or private insurance plan. They typically have service lines where you can call and share concerns. And likewise, if they have concerns that their insurers are not paying for care, they need, they can enlist their providers to help appeal those decisions.

We hear a lot of discussion in the news now about prior authorizations and whether insurance companies are willing to pay for care when doctors or other health professionals recommend it. So those are some of the steps that people can take, and then if they think it's a more systematic problem that their community is not being well-served, then working with other people in the community to bring their concerns forward to leaders of the healthcare organizations in their area, I think can be an important step as well.

If there's concern that it's not just an individual problem, but that groups of people or people living in certain areas are not being served well, if they can come together with local leaders and bring those concerns forward, it may allow for more systemic change in the way care is delivered.

Kelly Malcom:

This has been extremely informative, a little bit disheartening, but also there's some hope here because there are some recommendations and potential solutions. So I'll keep that in mind. But thanks again for coming on the show and talking to us today. We really appreciate it.

Dr. John Ayanian:

Thank you.

Kelly Malcom:

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