There is no doubt that we’ve made great changes in health and health care. Life expectancy has increased dramatically over the last century and many diseases have been eradicated or at least are better treated than ever before. There is also no doubt, however, that these advances are not equally distributed across the U.S. population. Black Americans, for example, have a life expectancy 3.8 years lower than whites, many minority groups have poorer health outcomes and higher incidence of a variety of diseases compared to whites, and despite equal levels of need are less frequently provided with procedures like hip replacements that can greatly improve quality of life.
Dr. Daryll C. Dykes gives a good overview of the history of legal efforts that have contributed to current health disparities. He also notes several provisions in the Affordable Care Act that address disparities in health and health care. These include increased access to quality health insurance and health care; expansion of Medicaid and the Children’s Health Insurance Program; health benefit exchanges (including outreach and marketing of those exchanges to meet the “needs of underserved and vulnerable populations”); tax credits for eligible households to provide assistance with premiums for health insurance purchased through the exchanges; and additional money for the operation, expansion, and construction of community health centers. These are general programs that benefit all of us, but theoretically will have a greater impact for groups, such as Hispanics and African Americans, who tend to have lower rates of employer-sponsored health insurance coverage.
There are also other measures targeted specifically at health disparities. These include efforts to diversify the workforce and the creation of the Patient-Centered Outcomes Research Initiative which has as one of its five priorities to identify “potential differences in prevention, diagnosis, or treatment effectiveness, or preferred clinical outcomes across patient populations and the healthcare required to achieve best outcomes in each population.” There are also expanded enforcement mechanisms that apply not only to intentional discrimination practices and policies, but also to those policies and practices that disproportionately impact minorities.
Why is this important? One example is illustrated in some of the work of Dr. Louanne Bakk who writes about, among other things, racial and gender inequities that have been unintentionally perpetuated through the structure and administration of Medicare Part D. (Full disclosure, she was one of my doctoral students and I’m very proud of her). Her research on Medicare Part D suggests complex relationships between the way a policy is structured and racial disparities, for example, racial differences in not adhering to prescribed medication use that are perpetuated or increased because of cost sharing measures embedded in the policy.
Also important is training current workers about structural racism and cultural competence. No matter our best intentions as individuals, unintentional bias can influence our interactions with clients and can shape organizational level policies and actions too. (Not to mention, of course, purposeful bias and discrimination!)
The Undoing Racism Workshops (URW) are one effort to address institutional racism. These workshops use “dialogue, reflection, role-playing, strategic planning and presentations” to challenge participants “to analyze the structures of power and privilege that hinder social equity and prepares them to be effective organizers for justice.” In a recent article published in Race and Social Problems, Mimi Abramovitz and Lisa V. Blitz surveyed URW alumni to examine the extent to which they have used what they learned to advance racial equity in their organizations. Respondents reported an increased knowledge and understanding of structural racism and most of them left the workshop motivated and more aware of how organizations can address racial equity. Not surprisingly, those who returned to a supportive organizational culture were more likely to engage in this work, with or without the active involvement of organizational leadership. More white respondents, however, reported having access to organizational decision makers while more people of color worried about getting into trouble at work and tried to keep a low profile when working for racial equity. A perfect example of how institutional structures and culture can thwart individual efforts.
Overall, while there was some progress toward racial equity in their organizations, it was limited. Interestingly, more progress was reported in organizations where the staff and the people served were more diverse, perhaps because the diversity in their organizations provided more pressure and motivation to engage in this work. (This also further supports the importance of working towards a diverse health and social welfare workforce).
Of course, this study only gives us a small snapshot of a tiny piece of a large and complex issue. But, hey, whole and beautiful pictures have been made from lots and lots of little dots.