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Three Policy Lessons to Advance Health Equity During an Ever-Evolving Pandemic

Jun 16, 2022, 11:00 AM, Posted by Jacquelynn Y. Orr

Many COVID policies and practices exacerbated longstanding health disparities. Here’s how we can change that going forward.

Capital Building

Since Omicron first appeared here in December 2021, the United States has had a 63 percent higher COVID death rate than other high-income nations. We also continue to experience deep disparities by race and ethnicity for risk of infection, hospitalization, and death from COVID. Even though federal agencies issued guidelines on how to stay safe, it was our local and state responses that explain many of the differences in health outcomes.

We turned to researchers working with Systems for Action, Policies for Action, and Evidence for Action, all signature research programs of the Robert Wood Johnson Foundation, to find evidence-based answers within policies, practices, and data to help explain these disparities. The questions included: Which responses worked best during the pandemic for our population as a whole and for communities at greatest risk? And how can we respond to future large-scale national emergencies in ways that better protect the health of vulnerable people and communities?

Here are three important lessons that emerged:

1. Pandemic Response Policies Must Protect People at Greatest Risk

While rapid policy responses to COVID (from physical distancing to temporary paid leave) were meant to protect the general public, many of these policies left out groups most vulnerable to the health and economic consequences of COVID-19. For instance, the federal Families First Coronavirus Response Act excluded some 60 million workers, including health care providers and first responders who could not stay at home or practice measures such as physical distancing.

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The Pandemic Underscored Why We Need Equitable Telemental Health Services

Mar 3, 2022, 11:00 AM, Posted by Daniel Do

Policies that increase access to telemental health services are key to ensuring mental healthcare is equitable and inclusive.

Online therapist talks with patient.

As a practicing social worker, I believe that mental healthcare is a right, not a privilege. LGBTQ+ and persons of color face numerous barriers to finding affirming mental healthcare and often experience racism and/or discrimination while accessing those services. Through support of the Robert Wood Johnson Foundation’s Health Policy Research program and in collaboration with my research partner Liana Petruzzi, I’m working to help shape a health and mental healthcare system where racism, homophobia, and transphobia are not tolerated or perpetuated.

The COVID-19 pandemic forced us to look at how trauma, stress, and a public health crisis combine to influence our mental health and wellness. This new reality drove the nation to significantly increase its investment in telehealth services. Now in our third year of the pandemic, we must reflect and ask ourselves if that investment is working, and more importantly, if it is equitable. We have a serious opportunity to better meet the needs of Black, Indigenous and People of Color (BIPOC) individuals and communities—needs that must not be ignored. 

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Closing the Medicaid Coverage Gap is a Health, Economic, and Moral Imperative

Sep 7, 2021, 11:00 AM, Posted by Avenel Joseph

Closing the Medicaid coverage gap would save lives, reduce costs, and help eliminate racial and ethnic health disparities such as maternal mortality rates among women of color.

Pregnant woman holding baby shoes.

Editor's Note: This post was updated in February, 2022.

“I am grateful for Medicaid because I can live on my own,” said Theresa, who has Spastic Quadriplegia Cerebral Palsy. Medicaid covers the costs associated with Theresa’s physical and occupational therapy, a wheelchair, and personal care attendants.

“I wouldn’t be alive if it wasn’t for Medicaid,” said Laticia, who received Medicaid coverage while growing up in the foster system that allowed her to receive care for both physical and mental health conditions.

“Medicaid has been a blessing,” said Regina, who relies on Medicaid to cover her daughter’s routine medical and preventive care that would otherwise be unaffordable.

There are approximately 75 million people in the United States enrolled in Medicaid, making it the largest health care provider in the country. And while each participant’s story is unique, Theresa, Laticia, and Regina have at least one thing in common: each lives in a state—Montana, Missouri, and Iowa, respectively—that has expanded Medicaid under the Affordable Care Act (ACA) to provide quality and affordable health care coverage to more of its residents. In fact, 38 states have done so since that landmark law was enacted.

But 12 states have refused to expand their Medicaid programs under the ACA, denying health care coverage to more than two million people—disproportionately people of color—who would qualify for the program if expansion was implemented in those states. These holdout states have refused to budge even as the federal government would cover the vast majority of expansion costs; even as Medicaid expansion states reap a variety of health and economic benefits; and even as the United States remains in the throes of a deadly pandemic.

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Database Tracks Health Equity Implications of State COVID-19 Policies

Jul 28, 2021, 2:00 PM, Posted by Julia Raifman

A publically available database is helping researchers, policymakers, journalists, and others understand how over 200 state policies implemented during the pandemic are impacting health equity.

COVID-19 U.S. State Policies image.

Rapid response is synonymous with moments of crisis. From first responders to communication experts, responding quickly to a crisis is critical for community health and well-being. But what about rapid response research? 

COVID-19 has epitomized a complex crisis of infectious disease, food and housing insecurity, and mental distress. People who are Black, Latinx, Native American, and living in low-income households are the most vulnerable to these conditions. It is clear that health and social policies enacted during the pandemic will affect communities for decades to come. 

To inform rapid response research and policymaking, my team at Boston University and I developed the COVID-19 U.S. State Policy database—also known as CUSP—in 2020. This resource aims to inform health and social policy decisions that promote health equity and focuses on policies that affect vulnerable and historically excluded populations. Now over a year after its inception, we are assessing what we have learned and where we have yet to go.

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How the Future of Work May Impact Our Well-Being

May 15, 2020, 9:45 AM, Posted by Paul Tarini

COVID-19 has rapidly compounded problems shift workers and gig economy contractors face, with implications for individual, family, and community health. What can we do to advance health equity in this new reality? Apply for funding to help us explore.

A man driving a car.

Editor's Note: The health impacts of our rapidly changing work environment are often overlooked. Since 2018, when this post was first published, we reported on the health equity implications of unstable incomes, unpredictable schedules, and lack of access to paid sick leave. In the wake of COVID-19, these questions about health equity are more important than ever. See what we’ve learned, and apply for funding to explore what the next five to 15 years may hold for workers.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as a rideshare driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on an app that links workers with gigs. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a 2018 report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today have no paid sick leave. Two-thirds lack access to employer-based health care benefits.

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Power and Opportunity in the States

Apr 18, 2019, 2:00 PM, Posted by Giridhar Mallya, Tara Oakman

State policymakers have more flexibility than ever to advance health-promoting policies and programs, and to showcase effective strategies from which other states—and the nation as a whole—might learn. RWJF helps inform their efforts through research and analysis, technical assistance and training, and advocacy.

Map of United States.

Why States Matter

States have long been laboratories for innovations that influence the health and well-being of their residents. This role has only expanded with the greater flexibility being given to the states, especially as gridlock in Washington, D.C. inspires more local action. The bevvy of new governors and state legislators who took office early this year also widens the door to creativity.

Medicaid is perhaps the most familiar example of state leadership on health. With costs and decisions shared by state and federal governments, the program allows state policymakers to tailor strategies that meet the unique needs of their residents. Among other examples, efforts are underway in California to expand Medicaid access to undocumented adults, and in Montana to connect unemployed Medicaid beneficiaries to employment training and supports.

In Washington state and elsewhere, Medicaid dollars can now cover supportive housing services, while Michigan is among the states requiring Medicaid managed care organizations to submit detailed plans explaining how they address social determinants of health for their enrollees. All of this experimentation is happening as states struggle to control the growth of their health care spending—a balancing act of immense proportions.

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Tool Informs Medicaid’s Business Case for Investing in Prevention

Apr 11, 2019, 1:00 PM, Posted by Martha Davis

State Medicaid agencies and managed care organizations will now be able to estimate the health impact and health care cost savings of investing in childhood obesity prevention initiatives.

Children play on a school playground.

Today, nearly 50 percent of children—over 35.5 million—are enrolled in Medicaid or the Children’s Health Insurance Program. These programs are essential to low-income children, and particularly children of color, who are more likely to lack access to other forms of health coverage. Both programs have been providing medical care to kids for about half a century.

However, the treatment of chronic illness, special needs, and adverse birth outcomes often receive higher priority attention than preventive interventions. This is because treatment for medically complex conditions drives costs in the health care system. So it is where state Medicaid agencies, and the managed care organizations (MCOs) that help them control cost, utilization and quality, invest their time and energy.

With most of the focus on treatment, it’s often difficult to make the case for community-based, family-centered prevention. But some states have started to implement prevention activities addressing childhood obesity and other areas of health promotion and disease prevention.

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A Free Clinic Builds “Bridges to Health” by Treating the Whole Patient

Dec 5, 2018, 11:00 AM, Posted by Catherine Malone

How one rural clinic addressed its patients’ complex health and social needs successfully—and cut emergency room use and costs drastically.

Dr. Steven Crane discusses a patient with a nurse.

There’s no bus service in his small town in rural North Carolina, so Dean* drives 10 miles to The Free Clinics ("Clinics") in Hendersonville every couple of weeks whenever he has money for gas.

Staff there helped him find affordable medications and treatments for cancer and for his shoulder, which he injured by falling 20 feet on a construction site. He’s unable to read due to learning disabilities, so they’ve also helped him find lawyers to file disability claims.

Dean is also one of the patients who attends the Clinics’ Bridges to Health ("Bridges") program, a drop-in group session where patients can discuss their social and emotional concerns as well as medical problems. He has battled depression since the age of five after enduring early childhood trauma. He credits the Bridges sessions, along with the Clinics’ holistic care, with easing his depression and improving his physical health, as well as “opening up avenues for me to get help.”

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Don’t Try to Fit Rural Health Into an Urban Box

Nov 12, 2018, 2:00 PM, Posted by Melissa Bosworth

In rural areas, lack of access to adequate care can be a matter of life and death. Transforming rural health requires creative, place-based solutions and a commitment to fostering local leadership.

A corn production farm.

The amputation was scheduled for that day. John’s* uncontrolled diabetes had stopped blood flow to his lower leg. With the tissue starting to die, it seemed inevitable that his foot would have to be removed to save his life.

Thankfully, a team I work with had recently helped bring telehealth services to the rural Colorado hospital where John had been admitted. A cloud-based video system connected to electronic health records enabled his doctor to consult with an infectious disease specialist hundreds of miles away in Denver. The specialist suggested one last “cocktail” of antibiotics, to be administered by I.V. The protocol worked. John kept not only his foot, but also his livelihood as a rancher: his ability to graze cattle, grow wheat, and provide for his family.

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How States Can Better Engage Medicaid Patients

Oct 29, 2018, 2:00 PM, Posted by Andrea Ducas, Tricia McGinnis

Experts weigh in on practical approaches for engaging Medicaid beneficiaries to ensure that services are designed to meet their needs.

People walking in a hallway of a government building.

Medicaid is the largest health care program in the United States and impacts the lives of more than 76 million Americans, nearly one-quarter of the nation’s population. The program can play a powerful role in influencing the health and well-being of individuals and families.

State Medicaid programs can only be truly successful, however, if they are responsive to the needs and priorities of the clients they serve—not providers, but patients and their families. Medicaid officials understand this. However, in the resource- and time-constrained environments in which Medicaid staff operate, finding the right avenues for gathering meaningful consumer input can be a challenge.

The Robert Wood Johnson Foundation has been trying to address these challenges through its work to transform health and health care systems. As part of these efforts, the Foundation along with the Center for Health Care Strategies recently engaged experts, including representatives from across the patient advocacy world, around this issue. These experts include leaders from Altarum, American Cancer Society Cancer Action Network, Community Catalyst, Georgetown Center for Children and Families, Nonprofit Finance Fund, and the Patient Advocate Foundation.

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