When we launched Where to Next our guiding principle was to examine the collective and systemic problems in America while putting a spotlight on the brightest individuals and companies working to solve them. One way we plan to do this is through the Acumen America Roundtable, where we'll get a group of people together whose lived experience and work in the field gives them a unique perspective on the positive, the negative, and what we can do to break down barriers in the current system.
Our inaugural roundtable explores the inequities in the American healthcare system, and some ways we can work to address them. Our three panelists are:
Monica Simpson, the executive director of SisterSong, an organization building an effective network of individuals and organizations to improve institutional policies and systems that impact the reproductive lives of marginalized communities.
Abner Mason, the founder of ConsejoSano, a company that helps non-English speakers navigate the country's complex healthcare system and get the treatment they need.
Pablo Bravo, the System Vice President of Community Health CommonSpirit Health, the largest non-profit health system in the country, where he has deep experience leading their community health efforts.
This conversation has been edited and condensed for clarity. The anchor links below can help you navigate the roundtable.
What are some of the major barriers to making healthcare more equitable in America?
How zip codes predict health outcomes
How community can help improve health outcomes
What the private sector can do
The government's role in improving health equity
What gives you hope for the future?
What are some of the major barriers to making healthcare more equitable in America?
Bravo: After the ACA passed that helped reduce the number of uninsured. However, in minority communities, the access to primary care physicians and specialists is still a barrier. So there is definitely an issue around access to the proper care. Most individuals [in these communities] continue to utilize the hospitals as their main source of getting care and that's really not an appropriate way to really address the health care of a community.
Mason: I'll jump in and completely agree with Pablo. One of the challenges we have with our healthcare system today is because of the extraordinary demographic change that we've seen in the country over the last 40 years or so. We're a much more multicultural country to the point where California, where ConsejoSano is headquartered, is a majority minority state. So is Texas. So is Nevada. According to the last census, the whole country will be majority minority by 2045. And that's five years sooner than the previous census. So we've had this huge demographic change and our healthcare system hasn't kept up with that demographic change. Our healthcare system in the U.S. functions today—especially in the way it engages the patient population or the health plan member population—like it did in 1970.
There's not much difference. So there's a mismatch between the system's ability to engage and build trust and to really connect with the people it's supposed to serve. That creates a disconnect between supply and demand, and then added to that we now know something maybe we didn't know 40 years ago: that a person's health is much more determined by non-directly clinical factors. They call them “social determinants of health.” If you don't have good food or any food, you're not going to be healthy. I don't care what the doctor does. If you don't eat or if you live in a place where the water is causing all sorts of terrible cancers and other kinds of things—no matter what happens at the clinic—it's too late. And so these social determinants, we know they profoundly affect a person's health.
Zip code matters a lot and we have to embrace that fact and then figure out the actions we need to take to address it.
Simpson: If I could just jump in here and say yes to all of what's already been said! To build off of what Abner was saying about the social determinants of health, to take that even further when thinking about barriers, we have to think about the way that race plays a role in the healthcare system of this country; and how historically communities of color and marginalized communities have lost trust. And that absolutely impacts the way that people show up. We started to really see this show up in a lot in our conversations around maternal health in this country.
Maternal health was one of the first places we really were able to really dig into this conversation around race, where the statistics were so blaring that black women were dying at a rate four times higher than white women in childbirth. That is because we were not addressing how racism absolutely plays a role in people's ability to get the healthcare that they need, and for folks to feel safe enough to get the healthcare that they need. So I think that is a huge barrier, it's a huge conversation that I feel like is now coming to the surface in this country and I think that we have to keep pushing that in order for people to get access to the healthcare that they need.
Bravo: I totally agree, Monica. And let's not forget about addressing bias. Bias sometimes has an impact on the correct access to care as well.
Simpson: If I can just add one more thing. Right now another piece of the work that we do in reproductive justice is really looking at the intersections of our lives and how they all come to play, which again goes back to what Abner was talking about in the conversation around social determinants of health. In this reproductive justice world were very much interested in not just maternal health; but also abortion access and access to contraception and different things like that. We have a ways to go in terms of narrative shifts around how we talk about reproductive healthcare as a part of overall healthcare and not creating a divide between those lanes.
How zip codes predict health outcomes
Mason: There's no question that if you are wealthier, you're going to have access to a whole host of aspects of life that are better than if you're poor—and healthcare is one of them. But so is your access to healthy food. So is your access to exercise. So is your access to education, which there's a direct correlation between levels of education and health; to use Monica's terms, there is intersectionality there. All of these things connect. If you're wealthier, you have more money, you are in a much better position to be able to have a healthy life. Low income people really struggle because of that intersectionality.
Frankly, if you are poor or low income, you are going to struggle and your health is going to be impacted by that. And because we live in a society that has a history—as Monica said—of racism and bias, and now overlaid on that an enormous impact of income. If you look at zip codes across the country, we still live in a racially-divided country. Most neighborhoods are still divided in two ways in America: by race and ethnicity and by income.
Zip code matters a lot and we have to embrace that fact and then figure out the actions we need to take to address it.
Simpson: You're so right, Abner. I would add to that, I grew up in rural North Carolina in the area code of 28174. This is Union County and if you didn't have access to a car getting to the closest hospital or medical facility was absolutely out of reach for you. There's no access to public transportation. There was no way for folks to really get what they needed. We didn't have a healthcare facility in my small town. And so we had to go to the next city over. The barriers there were just insurmountable for some people, and that really impacted their healthcare.
I now live in Atlanta, Georgia, where our office is for SisterSong, and we're in the 30310 area code, which is Fulton County; which is a huge metropolitan area, but it's incredibly African American. But looking at what it's like to move from these smaller, rural places to these more metropolitan zip codes and just the differences there. I saw it myself because I absolutely lived it. So I just wanted to just paint a personal picture of what Abner laid out. Zip codes are really determining what people have access to and how they're able to get the healthcare that they need.
Bravo: So from a healthcare provider perspective, in our facilities every three years we do a community health needs assessment and we use different mappings. When we look at those zip codes you see that the poor communities are highlighted in red because they have all these challenges: access to good education, good housing, transportation. So we try to address those health needs in those zip codes.
You can use these mappings and we'll show you how the life expectancies of these zip codes have a huge impact. But the lack of access to capital to be invested in those communities is still reflective today because of the lack of infrastructure, the lack of good quality access to transportation, education, clean water, those kinds of basic needs.
How community can help improve health outcomes
Bravo: I think community engagement, where individuals come together to really identify the priorities of that community and working together to address those issues as much as it can is really going to make a difference. Identify the leadership to be able to pressure local, county, and federal [governments] and anchor institutions to get involved in addressing the needs of the community.
Mason: I agree with Pablo completely, and I think one of the things is that healthcare writ large—all the healthcare stakeholders from health systems to plans to providers and the regulators—is starting to really see the important impact that social determinants of health have on a person's health. The good news is that the days of ignoring it and pretending those factors don't determine health and that they're disconnected from health are over. But we haven't figured out yet how to really start to address those, let's call it for this conversation, social services versus health services.
Typically, you would think that the social determinants would be addressed and then health services is how you address medical issues. I think it's pretty clear—or becoming clear—that that divide doesn't make any sense. It doesn't make sense to be spending a lot of money over here on health if you aren't addressing the social services, because you are not solving the problems, right? But how do we start to do more? My thinking is we need to have more coordination between health services and social services. In our country they're completely divided which makes no sense whatsoever. We have to figure out how we start to integrate more and then how do we invest more in social services because one of the ways community can help is what we call community based organizations.
Those kinds of nonprofits, they're in every community across America. They help with hunger, food insecurity, housing insecurity, domestic violence, and they can get transportation to people. They are an important part of solving this problem. They're not the only part of it. They're an important part of it, but right now they're disconnected from healthcare. Now healthcare is starting to say, which is a good thing, bowe need those community based groups, because we don't want to medicalize the solutions that these community based organizations can provide.
Communities have always played a role.
So the answer is not to take what the community based organizations do and have healthcare do it. It's going to cost 10 times more and they're not going to do it as well because the people who run these community organizations, they have their heart in it. They're close to the people they serve. They're nonprofits. These are people with compassion and a mission. One of the challenges is we have to figure out a way to direct revenue to the community based organizations because I think they are a big part of the solution, but today we do not have a mechanism for those groups to get the financial support and scale and maybe some capacity building so that they can really play the role they need to play—because I think that's a big part of addressing the social determinants.
If we don't use those community based organizations, who's going to do it? They're in the community already. So I think that's one area we really have got to figure out.
Simpson: I would honestly say that first of all, communities have always played a role. I think that what Abner was raising in his remarks is that we just have not amplified that work. There has been such a divide and there's so much of a siloing off of what happens at the grassroots community level and what happens within the larger healthcare system.
So I do think that there are more resources and more support that needs to go to community based organizations because they are the ones with their finger on the pulse every single day in these communities. However, I think that the other thing that's important too, is that there needs to be more amplification of this work. There's a role that the media needs to play. I think there's a role that our state and federal legislators need to play. There's a role that these individuals, these institutions, these entities have to play in helping to really amplify what's happening at the community level. And I think that will help us continue to bridge that gap that is, again, just all too apparent right now.
Bravo: I just want to add that while I totally agree community based organizations play an important role in communities, there's also a responsibility by business employers that they have to be engaged in the communities. If you go to a community where the only access to food is fast food, there's a huge food industry that needs to move in. So again, it's businesses have to also be held accountable and individuals in the community need to be engaged and create leadership. The other thing is that we need to start thinking about community resiliency and sustainability.
For example, it's great that there's a food bank in your local community, but yet that does not make you sustainable and resilient. It makes you dependent of a charity. We need to figure out a way to engage all the players in the community to make these communities a lot more resilient and independent.
What the private sector can do
Mason: I really agree with Pablo that companies definitely have a significant role to play in the communities that they operate in. So I think that's really important. I would add that when it comes to healthcare in particular, we need to make sure that innovation is seen through a health equity lens. I'll give an example.
Because of the pandemic, a lot of people know a lot more about virtual visits and telemedicine and telehealth. It became the thing when people couldn't get into the doctor's office. Telemedicine has been around for 10, 15 years—but it wasn't really used that much at all. And to the extent that it was used, it was for higher income people.
Truth is, a lot of the innovation in healthcare has been targeted to higher income people. I'll use California as an example. In California, federally qualified health centers are where low income people typically get their healthcare. Federally qualified health centers could not get reimbursed for virtual visits. So you have this new innovation that should be designed to let people get access to healthcare who couldn't get it before. Well, the low income people could not use that new innovation because they could not be reimbursed for it in California. There are other states like this.
So then comes the pandemic. Regulators put into place emergency regulations, and they say, “Okay, low income people. You can now use virtual visits. You can actually use telemedicine and we'll reimburse the clinic for it.” It took a hundred-year pandemic to allow low income people to actually benefit from an innovation in healthcare! If you think about it, innovations should expand access to everybody, but regulation got in the way and we didn't see those regulations through a health equity lens.
It's not just healthcare—it's education as well.
The good news is, I guess, pandemics sometimes forces us to think differently. So the emergency regulations allowed for low income people to use this innovation. As we move forward and we get the pandemic behind us I fear that the regulators will—I call it “slouching”— slouch back into their old form and they'll start to say, “Well, that was for emergency and we can't allow low income people to have access to these innovations.”
What I'm saying is, innovation is going to be very important to healthcare as we move forward. Virtual care is going to be a big part of healthcare as we move forward. And we need to make sure that the regulations that govern it—and even the innovators who are creating these new solutions—have a health equity lens on when they make decisions.
Bravo: If I can add, it's not just healthcare—it's education as well. I mean, we saw that minority communities did not have access to technology to be able to access the virtual class. So they might have to park themselves outside of a Starbucks to be able to get Wi-Fi. The technology that is available in some communities is not available in minority communities. And that divide has to be broken. There has to be access, equal access to these technologies.
Simpson: You both hit on it so much. I think that how I would put a bow on this ultimately, is if the private sector is not listening to the actual people and connecting to the people; at this point it just seems like there's so much opportunity for there to be more sharing of community and a deeper understanding of the real story that's happening on the ground with folks. That's the work that we feel is really important for the private sector—for all the different sectors to be quite honest—to know what's really happening. And I think that that's where we have some opportunity. Both pathways need to be open.
The pandemic gave us an awesome opportunity for what it looks like when we don't do business as usual, and that we actually center our communities and the needs of folks and the human rights of folks in healthcare in a way that I don't think that we had been doing. We need more of that.
The government's role in improving health equity
Mason: I believe that policy is one of the ways that we make sustainable change. If we can adopt the right policies, it does create a flywheel effect. It actually drives what the private sector does and what innovators want to do and what venture capital funds want to invest in. It's a connected system.
We still in America today don't collect race, ethnicity, and language data across healthcare the way we should. We don't have that data. And so how can you get a baseline of knowing where the disparities exist and then know how to invest in programs that can address those disparities if you don't have any metrics?
Policy is really important to create a sustainable change that will lead us to a more equitable healthcare system.
We know our healthcare system has disparities based on race and income, but if we don't have better metrics around it, you cannot effectively decide where to invest, what programs to invest in, and measure the success of the programs. So I think we need to collect race, ethnicity, and language data. The government's going to have to finally say this is absolutely required.
Another example is we should tie incentives to close gaps in care. Let's say we collect race and ethnicity data. We start to know where the gaps are, what the disparities are. We should incentivize healthcare stakeholders or punish—you know sticks and carrots. I tend to be a more of a carrot guy than a stick guy, but we should incentivize people to close those gaps in care and that again is policy. And the two programs where you could really make the most headway are Medicaid and Medicare Advantage and Medicare, because those are the government programs that regulators really control.
There are other examples, but policy is really important to create a sustainable change that will lead us to a more equitable healthcare system.
Simpson: Oh boy. Yes. There's so much that we need to address from a policy perspective at the state level, as well as the federal level. First, it's important for us to think about the fact that there are still way too many barriers at the policy level that just need to be addressed. When I think about reproductive healthcare in this country, we're still fighting the Hyde Amendment and the Helms Amendment. We now have abortion bans popping up [at the state level].
We've seen what it looks like whenever we do have elected officials ready to move with the will of the people and where people are going, from a justice perspective. When I look at the big strides that have been made in the maternal health field, we saw a proclamation come down from the highest office: from the president around Black Maternal Health Week.
All of this sends major signals down to our community that our lives matter, that what we need matter, that we have elected officials that are on our side and willing to move the work. And so that really creates more momentum. It creates more trust. It creates more opportunities.
Whenever we use policy as a way to push us forward in terms of a justice lens, I think that's what's going to get us to where we need to be.
Bravo: And not just to engage on the loud voices, but also engage with voices you don't like. For example, rural communities. Their voices are not that loud. So they're almost ignored and the needs in rural communities are tremendous. So the advocacy and the policy has to be leveled equally on those silent voices that you can barely hear.
What are some positive changes you've seen through your work or lived experience?
Mason: One of the most encouraging things I've seen recently is with the Medicare Advantage program. There's a new rule that allows the Medicare Advantage Plans to spend some of the premium dollar on upstream or social determinants of health issues. It's called the Supplemental Benefits Program. This is a sea tide of change coming from the Centers for Medicare & Medicaid Services, that it recognizes the importance of these social determinants of health issues and it allows the Medicare Advantage Plan to spend some of the premium dollars to address it. This is the direction we should be going in.
Now the sad thing is Medicaid Plans don't have the same flexibility. And yet the need to address social determinants of health is greater in the Medicaid population than the Medicare Advantage population. The good news is, we're taking a step. The bad news or the less good news is that we are not including Medicaid, but I think it's coming.
Simpson: I will say that we've seen the conversation of race happening more in healthcare. For me, that's a win. For the work that we do, that's a win—because we know that that is at the root of so many of the issues that we're dealing with around our work. And so the fact that these conversations are starting to surface more within legislation, within the healthcare system, within medical schools, I mean, people are talking about it in ways that I just haven't seen over the past decade or so. And that's something I want to lift up in this conversation, because I know it's incredibly important to the communities we serve.
We're seeing these small strides, and I think that once we continue to accumulate these small strides, we get the bigger wins that we want.
Then we've also seen some elected officials finally coming on our side, being able to really talk about abortion access and reproductive healthcare in ways that has been very difficult. It's such a highly moralized and stigmatized issue that it's pushed a lot of people out. But we need to see more people come to this conversation, come to legislation like the EACH Woman Act. Just thinking about the ways that we've been able to move at the federal level some positive and proactive measures has been really promising for us.
And then also thinking about the ways that we've been able to really interact with the courts. We've had some serious defensive places that we've had to really muster through, but we've seen a ruling come down that we were on a case with American College of Obstetricians and Gynecologists, where we were able to get some of those restrictions for folks being able to go pick up their abortion medication.
We're seeing these small strides, and I think that once we continue to accumulate these small strides, we get the bigger wins that we want.
Bravo: I'm going to add a different area. One of the exciting pieces I think that I'm seeing now is looking through the lens of an anchor perspective, where we, as an organization, for example, we're looking at local hiring wherever we have a hospital. Local hiring is really important, local purchasing, investing in the communities that we serve and engaging with advocacy groups. From an anchor perspective, using all those tools to be able to improve the equality and the healthcare of communities. I think that that is a really interesting movement that's been growing a lot and engaging in quite a bit.
What gives you hope for the future?
Bravo: The conversations and the work that's being done around equity and inclusion is very hopeful. I think the understanding of the need to address some of the basic needs in housing, transportation, education; it brings me hope.
Mason: The thing that I find most hopeful is that the experience that we've had as a world—and certainly as a nation—with COVID and th
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