Problems rarely fix themselves.
That’s why Dr. Creshelle Nash, Arkansas Blue Cross and Blue Shield’s medical director for health equity and public programs, says organizations must approach improving health equity internally and within their communities with purpose, integrating a health equity framework into their ways of doing business. She says doing so not only makes employees healthier, it enriches communities, increases productivity and lowers employer health costs.
For example, Nash says that in 2021 when Arkansas Blue Cross launched its Vaccinate the Natural State campaign, in addition to getting the message out statewide, they took care to reach out to three specific minority communities of Arkansans disproportionately affected by the pandemic and who had expressed resistance to the prospect of getting vaccinated: Marshallese, Hispanic and Black Arkansans. She told the organization’s leadership, “We have to have intention to reach them. We must build it into our plan; health equity doesn’t happen by chance.”
Health equity can be incorporated into organizations in countless ways. But first, Nash says many people are often unfamiliar with the term “health equity” or confused about what it entails.
What it means
“There are many popular terms thrown around now: health equity; health disparity; Social Determinants of Health; Diversity, Equity and Inclusion (DEI),” Nash says. “They don’t all mean the same thing. They’re related but different.”
She says equity is a part of quality: “We can’t say we have a quality healthcare system if the care received varies by the color of your skin or your gender or age or where you are. I want to have a healthcare system that meets the needs of everybody.”
Her favorite definition of health equity was penned by the Robert Woods Johnson Foundation: “Health equity is achieved when everyone has the opportunity to meet their fullest health potential, and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Nash says health equity encompasses the ingredients of a safe and fulfilling life.
Barriers to healthcare commonly experienced by Arkansans can include poor access to providers, hunger, unemployment, discrimination, lack of transportation, financial instability, cultural distrust and unsafe living conditions, among many others. These barriers can disadvantage anyone, not just minorities, though Nash says minorities and underserved populations are often a focus of health equity efforts because they tend to experience a disproportionate number of roadblocks to getting high-quality healthcare.
The messenger matters
Working together to address inequities is a throughline in Nash’s 30-year career as a general internist in private practice, Harvard-educated minority public health expert, health policy advocate, researcher, mentor and health insurance medical director. Nash says one of the best ways to approach health disparities is partnering with organizations and local leaders who have expertise in addressing these barriers and have earned the community’s trust.
“The messenger matters. … We partner with minority healthcare providers and leaders across the state, providing them with accurate information to use in their own community outreach,” Nash explained.
“When we work together to remove barriers, we each have the opportunity to be as healthy as we possibly can,” Nash says. “And that’s good for all of us, not just the people who are experiencing the problem.”
Arkansas health disparities
Health disparities in The Natural State are widespread and well-documented.
Among other findings, a 2022 Kaiser Family Foundation report determined that:
- Black, Hispanic and mixed races have higher rates of poverty in Arkansas than whites do.
- The state’s American Indians (32%) and Blacks (24%) smoke at higher rates than the average of all adult Arkansans (18%), while the national average of U.S. smokers is only 11.1%. In terms of percentage of smokers, Arkansas nationally ranks in the top five states.
- Nonelderly Hispanics in Arkansas are uninsured at a more than 3 to 1 rate compared to their white counterparts.
- Hispanic Arkansans who report that they don’t have a personal doctor are 37.5% of that population compared to an overall 10.8% for all adults in the state.
- In the U.S., nearly 1 in 3 adults is obese, but in Arkansas the obesity rates are much higher: 37.4% of whites, 48.3% of Blacks and 38.1% of Hispanics.
Nash says the disparities in quality of care received by racial and ethnic minorities is alarming. The 2022 National Healthcare Inequities and Disparities Report issued by the the federal government’s Agency for Healthcare Research and Quality found:
- The decline in life expectancy was greater in Hispanic (decrease by 3.0 years) and non-Hispanic Black (decrease by 2.9 years) groups than in non-Hispanic White groups (decrease by 1.2 years), widening an existing health disparity.
- American Indian and Alaskan Native patients experienced worse quality of care than white patients in 43% of procedures.
- Hispanic people and non-Hispanic Black people consistently experience worse care on most measures of breast cancer care, among other areas of care.
- About half of all births are to people from racial and ethnic minority groups. Research indicates that pregnant people from these groups often experience the highest rates of adverse health outcomes. Even when accounting for risk factors such as maternal age, income and receipt of prenatal care, racial and ethnic minority individuals continue to experience significantly worse outcomes.
The health disparities of rural Arkansas compared to city-dwellers are well-documented, too, and people of color are affected by most disparities at rates outpacing white Arkansans.
What’s especially problematic overall, though, Nash says, is that these “outrageous” numbers have become normalized. “Whenever we see Arkansas on a list, what do people assume? ‘Oh, Arkansas, you’re at the bottom of the list again. Thank God for Mississippi!’ These disparities have been around so long, people start to see them as acceptable permanent states,” she says.
But, she says, these are fixable problems. “I’m not saying they’re fixable in the short term or with one simple intervention, but we have opportunities to make them better. The last three years of the pandemic have shown more people in real time what the problems are and how we need to address them collectively.”
Maternal heart health
She says one important area needing more health equity is maternal cardiovascular care. “Cardiac issues are one of the biggest issues mothers can experience post-partum, but awareness of the risk is low,” Nash says, explaining that lower-income and rural populations without ready access to obstetricians often don’t receive the thorough pre- and post-natal care that women who are well-insured do, leading to higher rates of post-partum cardiac problems for these patients. She and a colleague recently facilitated a meeting with the Association of Black Cardiologists to leverage their expertise and start working together on this issue.
Still, she cites cardiovascular care as an area where women’s health has made substantial advances.
“Years ago, when women would come into the ER with chest pain, they were often told, ‘Oh, you just have anxiety.’ Because providers were looking for women’s symptoms to present just like men presented, and we don’t,” she says. “Now, we have a better understanding of women’s heart health. That’s an example where health equity for genders has gotten better over the years. We listened and learned instead of dismissing women’s concerns.”
Saving costs, saving lives
Nash says the costs of health disparities are staggering and contribute to overall societal costs and burdens. She cited U.S. statistics* from 2016 to 2018 that determined health disparities created an average of $93 billion in excess costs and cost employers $42 billion in lost productivity.
Aside from the moral and altruistic motivations often attributed to health equity leaders, Nash says it also makes smart business sense.
“Health equity is specifically a strategic advantage,” she emphasizes. “It saves you labor costs, increases productivity, decreases the expensive health claims. To be able to develop all people to their fullest will make your business better, will make your communities better, will make this nation better economically for the future.”
Start with the data, then innovate solutions
To benefit their own bottom line, Nash recommends each employer first look at their employees’ collective health to identify the biggest problems, expenses and barriers to care, paying particular attention to health inequities in anonymized data. Another suggestion she offers is to survey the employees about their experiences and use them to help identify what their population’s issues are. Then, strategize creatively about what they could do to make the issues better.
“Build your solutions on a foundation of data,” she tells organizations. “You have to understand what your population’s pain points are before you can fix them.”
For example, if a company has a lot of employees with diabetes, she suggests it could be worth looking into adding a diabetes management component as part of the benefits design. “Try to remove barriers to care and provide incentives to support healthy actions,” Nash advises. Ideas such as starting a workplace wellness program to support employee health and wellbeing, offering discounted gym memberships, increasing nutritious food options at worksites or bringing in diabetes professionals to give free talks or webinars to the staff could be effective. She tells groups to bring their own ideas—and their employees’ feedback—to the conversation.
What matters is adopting measures that are helpful and sustainable for each organization, including collaborating via the community partnerships at the core of health equity. Because, she says, just as the barriers, disparities and the Social Determinants of Health are connected, it takes people working together to make measurable progress.
“When community members have health equity, they cost less money to support and are better able to prosper,” she says. “Everyone benefits.”
Paradigm, not a project
Fixing the systemic barriers too many people face is more than a project. Nash says it needs to be a framework integrated and infused into everything organizations do, a way of approaching problems with a wider, more inclusive view. That is her mission.
“To me, it’s not a program. It’s not an initiative. Health equity should be integrated into all our systems, into who we are, what we do and how we do it so we can take care of our members and the communities we serve,” she says.
“I think one of the beautiful things is that in this unique experiment that is the United States, everybody should have the opportunity to pursue whatever their goal is,” Nash says. “We know we have not reached that state in all communities, and we have many challenges. But we must remove barriers, including to healthcare, so people can reach their goals and full potential.
“And working together, we can get there.”