A Historical Timeline of Advancing Health Equity
Understanding and Addressing Disparities
In 2003, a groundbreaking Institute of Medicine (IOM) Report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” concluded that, by and large, People of Color receive lower quality medical care than white people. In 2005, inspired by the IOM report, the Robert Wood Johnson Foundation launched a national initiative, Finding Answers: Disparities Research for Change. Finding Answers focused on moving the disparities field beyond simply documenting racial and ethnic differences in health care to supporting efforts to eliminate them.
Over ten years, Finding Answers awarded grants to 33 organizations focusing on cardiovascular disease, diabetes, and depression. They were diseases for which the evidence of racial and ethnic disparities was strong and recommended standards of care were clear. Participants were asked to think expansively about how they could improve care for their patients, whether it was redesigning existing care delivery systems, creating new partnerships with community-based organizations, or encouraging providers to reduce gaps in care with targeted incentives.
Finding Answers culminated in the development of the Roadmap to Reduce Disparities—later named the Roadmap to Advance Health Equity—based on: the findings of the grants program; systematic reviews of disparities intervention literature; and the experiences of organizations that implemented the Roadmap. The continuously evolving Roadmap is a guiding framework that integrates a culture of equity with concrete technical steps to enact care delivery transformations.
Leveraging Payment Reform to Reduce Disparities
During Finding Answers’ program life, the health care arena was rife with experiments in value-based care and payment reform. Various organizations conceptualized and tested ideas such as: patient-centered medical homes, accountable care organizations, and bundled payments. The Robert Wood Johnson Foundation launched a series of investments to learn from and help spread those models. It later began to help make collective sense of the shift toward alternative payment models through establishing a learning program with AcademyHealth.
As alternative payment models continued to proliferate, what was missing from the national dialogue and efforts to implement them was a consideration of healthcare disparities. In fact, some early research began to suggest that, if not designed carefully, alternative payment models had the potential to exacerbate existing health disparities or create new ones. While there was ample evidence about how to identify and reduce disparities via quality improvement, such programs had historically been under-resourced or financially infeasible for the long-term.
In 2014, with developing alternate payment models attuned to addressing health disparities in mind, RWJF connected Finding Answers with a group of payment reform experts. They worked together to create a new program that combined efforts to advance and learn from payment change with a commitment to eliminating disparities in health care and outcomes. That program, Finding Answers: Solving Disparities through Payment and Delivery System Reform, worked with three grantee partners to examine how disparities interventions could be supported by innovative payment methods—primarily through state Medicaid programs. Each grantee initiative consisted of a health care delivery organization and a payer to explore promising ways to reduce disparities by paying for equity-focused care transformation differently and to share practical lessons with other organizations wanting to do similar work. Finding Answers learned that while some disparities interventions may save payers or providers money in the long run, measuring, reporting, and reducing disparities requires immediate commitment, infrastructure, experimentation, and staff time. From the earliest stages, initiatives must be designed to support the resources needed. They must also reflect in-depth knowledge of what key stakeholders view as priority metrics that will inform and encourage long-term sustainability. Payment models should be flexible and allow for experimentation and the transformation of a care system in whatever way is most effective. Finally, Finding Answers learned that in order to best position payment models to have that degree of flexibility within the context of a Medicaid managed care organization, the State Medicaid agencies that set the contract terms with those payers must be a partner at the table in developing the models.
Transforming Systems to Address Disparities
In 2018, Finding Answers was reimagined as Advancing Health Equity: Leading Care, Payment and Systems Transformation (AHE). Along with the change in name, the organization furthered its commitment to improving medical care for Communities of Color and others living with health inequities. It grew into a partnership between the University of Chicago, the Center for Health Care Strategies, and the Institute for Medicaid Innovation as the program initiated a new learning collaborative (LC). The learning collaborative brought together teams of state Medicaid agencies, Medicaid health plans, and frontline healthcare delivery organizations. The LC was created with the belief that together, organizations can develop shared equity priorities, understand the drivers leading to health and healthcare disparities, and create payment models designed to support equity-focused care transformations.
The AHE learning collaborative hit its stride in the midst of the COVID-19 pandemic. The stark disparities in morbidity and outcomes for COVID-19 by race/ethnicity and socioeconomic status, as well as simultaneous public outrage at police brutality against People of Color, heightened awareness of systemic racism. It accelerated the pace at which individuals and organizations became ready to take their work a step further and tackle systemic racism and social determinants of health as drivers of health inequities. Accordingly, participating LC teams began to consider their work in a new light. These realities highlighted the need for authentic engagement and partnership with patients and community members living with the specific health inequities that were being addressed by the LC team initiatives. It also illustrated the need to connect internal organizational change efforts focused on equity with how health plans, Medicaid agencies, and providers actually do business and deliver care. The LC illustrates AHE’s belief that there’s no time like the present to learn by doing.
The Road Ahead
In 2021, AHE continued to champion pragmatic solutions grounded in research and rooted in person-centric approaches to health care. As a program, we began explicitly incorporating principles of antiracism in all of our initiatives and training, and have deepened our commitment to authentic community engagement. AHE believes that power imbalances must be acknowledged and mitigated so those receiving care have just as much say in their health as those administering it. When power and resources are held primarily by health system organizations, it leaves patients and communities little to no voice on issues that directly impact their health. Change must happen simultaneously from the top down, the bottom up, and the middle out. AHE will encourage that multi-directional change through the next iteration of the AHE Learning Collaborative, which launched in 2022.
A rising tide does not necessarily lift all boats. In fact, one-size fits all approaches lend themselves to engendering low-quality care that does not recognize the unique needs faced by various communities. By not actively exploring ways to eradicate gaps in medical care faced specifically by People of Color, inequities in health will persist and people will continue to receive substandard care. Advancing Health Equity is part of a movement to ensure equitable care for people of all races and backgrounds. It is no longer a question of why, but rather how to address systemic racism as a foundational aspect of health equity.