Title
Racial Disparities in Healthcare/ Are US Healthcare Systems Doing Enough for Black/African Racial Minorities?

Abstract
Since the racial reckoning conversation was catapulted into the global space by the cruel murder of George Floyd on May 25, 2020, there have been widespread pledges of policy changes in United States institutions, justice and healthcare most prominent, attempting to address many long-known and proven health disparities between racial groups. The new policies to correct the racial health disparities, known as Race Equity Policies in Healthcare, are aimed at improving health outcomes for racial minorities by (1) improving access to quality healthcare for racial minorities, (2) improve experience of racial minoriti (Preprint)
Authors: Yunusa Rabi , Abdallah Marwa , Jaman Patience 
Published: January 2024

BACKGROUND

On June 19th, 2020, just 25 days after the brutal murder of George Floyd, 36 healthcare systems in Chicago, one of America’s most racially segregated cities, issued a joint statement and laid bare their plans to tackle healthcare disparities facing its black population and communities (Uchicago, 2020). Many other health institutions, organizations of public health and health departments finally named racism as a public health crisis and an emergency that must be tackled as such (APHA, 2020). These institutions enacted new policies to specifically correct the racial health disparities known as Race Equity Policies in Healthcare and are aimed at eliminating racial disparities and improving outcomes by (1) improving access to quality healthcare for racial minorities, (2) improve experience of racial minorities when in contact with healthcare, and (3) improve diversity in representation of racial minorities in significant power positions within the healthcare workforce. These policies when fully adopted and implemented will chip away at the scourge of systemic, structural, and institutionalized racism in healthcare which have long been proven to negatively impact the way black Americans and other racial minorities experience health and healthcare in the United States. Of these race equity policies instituted by the health institutions in America, we examined those policies aimed at improving access to healthcare to previously marginalized black people they purport to serve.

OBJECTIVE

To assess healthcare access for black people living in communities served by healthcare systems that have adopted and implemented race equity policies.

METHODS

Methods

Data
The study utilized secondary data originating from published CHA reports published by 10 large US health systems located in 8 geographical counties of 8 US states. Counties included were Shelby AL, Dougherty GA, Cook IL, Baltimore MD, Bertie NC, New York NY, Philadelphia PA and Harris TX. Each of these counties is served by a unique health system, that form part of a group of Health Systems that together served >60% of all Americans. We used the most recent CHA report published before June 2020 as pre-policy/ baseline data, and CHA published in 2022 and 2023 as post-policy data. Using data in 2022/2023 means a reasonable amount of time has passed for policies to influence the health outcomes we are measuring.

Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional review board (IRB) of the University of Washington, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was not needed as all data were open sourced online from the sampled health systems analyzed in the study. All data sources were waived from review by the Institutional Review Board at the University of Washington.

Protected populations
The study was entirely conducted using publicly available open access de-identified secondary data. No specific protected persons, organizations or vulnerable population were included or named in the study.

Inclusion & Exclusion criteria
The IRS requires, among other things for tax exempt hospital organizations to file a Community health Needs assessment (CHNA) to retain tax exempt status of Section 501(c)(3). IRS provides rules on conducting a CHNA as outlined in Section 501(r)(3) and tax-exempt organizations must be compliant in order to maintain the tax-exempt status. The IRS requires that CHNA be conducted in a taxable year or in either of the 2 immediately preceding taxable years (i.e at least every 3 years) and to adopt an implementation strategy to meet the needs identified through the CHNA. Furthermore, the CHNA must “take into account input from persons who represent the broad interests of the community served by the hospital facility…” and be widely shared with the public (IRS, 1969). All the organizations we included in the study satisfy this IRS tax exempt status of Section 501(c)(3) and have filed a CHA for time periods between 2016 and 2023 under sections 501(r)(3)(A) and 501(r)(3)(B).
Secondary data included came from CHA reports published publicly as required by the IRS of all non-profit health institutions every 3 years. Where there are gaps in the data or a health indicator was not reported, we used local county health department data to fill those gaps. Only counties with a minimum of 12% black population were included. Only health systems serving high black population density counties of a state were included. We excluded secondary data reported by hospitals and clinics serving non-black or black minority communities. We excluded data from either the health systems or government derived data that did not provide information about black/African racial minorities. We excluded data from smaller health institutions regardless of their geographical location.

Statistical Analysis
This is a quantitative cross-sectional survey using readily publicly available open access secondary data from Community health Needs Assessments (CHA) and government data. We examined 7 health access indicators using publicly available community health assessment reports of 10 large healthcare provider organizations serving 11 majority black counties in 10 US states previously reported to have the poorest health outcomes for their black populations when compared to the national average. The health access indicators measured were (1) Black access to health insurance and Medicaid (2) Maternal Mortality (3) Infant Mortality (3) Preterm Birth (4) Black Teenage Pregnancy (5) Participation of black pregnant women in prenatal care during the first trimester (6) Community Health development (7) Representation of black people in the health workforce. We de-identified specific health systems names to center our work on calling-in accountability, not calling-out. We then performed paired T-tests using R software to measure change pre- and post- race equity implementation. Maternal Mortality data used were those death due to pregnancy related causes. Poverty was defined based on DHHS criteria of 138% below Federal Poverty level (FPL)

RESULTS

We found that despite these new race equity policies being implemented, access to health insurance including Medicaid continued to be abysmal. We found that a very slight improvement of black employment status did not coincide with any reduction in poverty, which in fact worsened. While overall Black uninsured rates for all ages improved, there was worsening of black Medicaid coverage for all ages.
Over time, we found significant improvement in black Infant mortality rates (p=0.00001) that was not mirrored by maternal mortality, (p=0.25, maternal mortality improved only moderately).
We found only three of 8 counties included in the study (Cook County Illinois, Baltimore County Maryland and New York County New York) had clear policies to hire and retain people of color in the health workforce, an important component of organizational cultural competence.
We observed that all counties implemented and practiced low impact or soft equity policies such as monetary contributions and donations to community organizations. However, concrete equity policies on community partnerships such as long-term investments in communities such as diverse hiring practices, hiring community health workers or adding structural buildings such as a community clinic were generally lacking.

CONCLUSIONS

Race Equity Policies in Healthcare Systems should be welcomed and encouraged by both state agencies and health systems. At the State level, Medicaid should be expanded across all states, proactively made accessible to all vulnerable groups and cover case management including community outreach; eligibility across the life course should be expanded. When health system access depend on affordability and racial identity is intersecting that disparity, it is imperative that well-meaning state governments to immediately see the benefit of expanding Medicaid as a means to alleviate poverty as healthy people are more likely to be employed. In this case, Medicaid expansion including raising the income eligible to 400% FPL, to widen eligibility and cover more people without increasing poverty, or people staying very poor so as to qualify for Medicaid.
In the Health Systems, race equity policies that improve diversity in healthcare workforce must be addressed. Cultural competence as well as professional competence must be a priority. No provider with no current experience in labor and delivery should be allowed to handle them. Health systems should partner with communities to increase their diverse workforce with programs such as increased physician hiring, community health worker hiring and supporting/ investing in the medical education of diverse groups so they can enter the workforce in future.
Proper and clear risk assessment measures should be adopted, enforced and priority given to racial minorities’ health care concerns such as maternal mortality. Review panels should be empowered to support all strategies to end the maternal mortality disparities and prevent untimely death of black women and other minorities.

CLINICALTRIAL

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