The economic, employment, and racial disparities detailed in County Health Rankings and Roadmaps’ 2022 Annual Report have a ripple effect across all social determinants of health. Access to all basic human needs is at issue and must be addressed.
County Health Rankings and Roadmaps (CHR&R) released their 2022 annual report this week, and what a read it is! Those in the health equity space unfamiliar with this resource need to get familiar quickly! The site provides current data and outcomes on societal disparities for every county in the United States. CHR & R was created by the University of Wisconsin Population Health Institute with funding from the Robert Wood Johnson Foundation. The site is among my favorite “go to” sites for health disparities data, along with CMS’s Mapping US Medicare Disparities and the Health Equity Tracker courtesy of the Satcher Health Leadership Institute and Morehouse School of Medicine). But, back to those CHR & R the interesting results!
What the Data Reveals
Much has been written during the pandemic about economic shifts and their impact on the population. The results of the CHR & R report are glaring, and have strong potential to impact wholistic health equity across physical, behavioral, and psychosocial health:
- Many US residents do not earn a living wage: $35.80 an hour for households with one adult and two children:
- In nearly all US counties, the typical wage is less than the living wage for the area. Among these counties, a more than 73% increase in wages is necessary to meet the living wage; some counties require a 229% increase.
- The gender disparity gap is only eclipsed by that for racial disparities:
- Women earn 81 cents on the dollar relative to White Men
- Women of all races and ethnicities must work more time to earn the $61,807 average annual salary of a White man.
- Asian Women: 34 days more (approximately 1 month)
- White Women: 103 days more (> 3.5 months)
- Black Women: 223 days more (> 7 months)
- American Indian/Alaskan Native: 266 days (>8.5 months)
- Hispanic Women: 299 days more (approximately 10 months)
- The largest pay gaps exist in the South and Western Plains States, often related to prevailing systemic racism
- Childcare costs negate the ability of many parents to work, and is considered unaffordable when it exceeds 7% of the household’s income:
- No counties have the childcare cost for two children at or below the 7% benchmark
- On average, a family with two children spends 25% of its household income on childcare
- Childcare cost burden is highest in urban metro regions and rural counties: 27% and 25% respectively
- For a person earning the federal minimum wage of $7.25-an-hour, the average childcare costs for two children is >90% of their annual income.
- Vast educational disparities appear across rural, suburban and urban schools:
- 50% of all counties in the US have a public school funding deficit, needing to spend >$3,000 more per student, annually
- 70% of counties with deficits of > -$4,500 per student, annually, are rural
- Counties with higher proportions of Black, Hispanic, and American Indian & Alaska Native populations have funding deficits higher than most US counties; deficits are especially high in certain areas, such as the Southern Black Belt region (systemic racism hits again).
- Large school funding deficits (-$4,500 per student, annually) correlate with students performing below their grade level for reading and math.
Ripples Effects and Recommendations
The economic, employment, and racial disparities detailed in the report have a ripple effect across all social determinants of health. Access to all basic human needs is at issue, and must be addressed. The report includes a series of data maps, resources, and successful programming to mitigate the issues. Recommendations encompass, but are not limited to:
- Increasing access to affordable childcare through publicly funded pre-kindergarten programs, child care subsidies, preschool education programs, and Early Head Start.
- Improving community conditions and increase access to financial resources to preserve affordable housing, via Community Development Financial Institutions, Community Development Block Grants, inclusionary zoning and housing policies, housing reparations, and Tax Increment Financing (TIF) for affordable housing.
- Building social connectedness, cultivate community power, and promote civic engagement by addressing barriers to participation in policymaking, resource allocation, information sharing, and collaboration in neighborhoods, schools, and workplaces (e.g., community schools, school-based health centers, youth leadership programs, community health workers)
A table with additional measures and data sources are appears at end of the report, which reaffirms the product’s value to the industry. The report is accessible from the embedded URL above, or through the County Ranking and Roadmaps site, www.countyhealthrankings.org
Feel free to add your comments about this blog post below, or other valuable resources.
“Communities take care of their own”; that is especially true in attaining health equity. Was this grand effort by CMS too little, too late? Industry stakeholders have stepped up to lead the efforts for the population, and are now running far ahead of CMS.
News outlets were flush with reports last weeks of the latest happenings in the Social Determinants of Health (SDoH) space. The top stories were all aligned with press releases from the Centers for Medicare and Medicaid Services (CMS) touting efforts to address “Systemic Inequities” as part of their, 2022 Strategic Plan.
The bold effort encompassed:
- Release of the Inpatient Prospective Payment System 2023 Rule, including the health equity trifecta of:
- Request for public comment over the next 60 days on means to enhance and/or standardize SDoH documentation through data collection of inpatient claims and metrics that analyze disparities across programs and policies, including a request for information related to homelessness reported by hospitals on Medicare claims
- Update of the Hospital Readmissions Reduction Program (HRRP) to improve performance for socially at-risk populations, and
- Implementation of “birthing friendly” hospital designations to improve maternal health outcomes and reduce associated morbidity and mortality.
- Commitment by (CMS) to mitigate health disparities through efforts aligned with Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities through the Federal Government.; all CMS offices are to embed health equity into the core of their work:
- Aimed to better identify and respond to inequities in health outcomes,
- Barriers to coverage, and
- Access to care.
The means to achieve these efforts included a robust plan that looks great on paper:
- Close gaps in health care access, quality, and outcomes for underserved populations.
- Promote culturally and linguistically appropriate services Build on outreach efforts to enroll eligible people across Medicare, Medicaid/CHIP and the Marketplace.
- Expand and standardize the collection and use of data, including race, ethnicity, preferred language, sexual orientation, gender identity, disability, income, geography, et al. across CMS programs.
- Evaluate policies to determine how CMS can support safety net providers
- Ensure engagement with and accountability to the communities served by CMS in policy development and program implementation
- Incorporate screening for and promote broader access to health-related social needs, including wider adoption of related quality measures, coordination with community-based organizations, and collection of social needs data in standardized formats
- Ensure CMS programs serve as a model and catalyst to advance health equity through our nation’s health care system, including with states, providers, plans, and other stakeholders.
- Promote the highest quality outcomes and safest care for all people using the framework under the CMS National Quality Strategy.
Yet, my antennae shot up while reading one CMS quote:
“ The agency will bring together healthcare stakeholders—including payers—to promote implementing a health equity strategy. The first meeting will address achieving health equity in maternal healthcare, specifically. It will occur during the summer of 2022.”
Time to hurry up and wait. It seems the health equity strategy is not totally defined: shocking, I know! My elation at seeing formal acknowledgement and attention to, systemic inequities, was quickly dashed. Advancing legislation and funding for the SDoH alone will not fully mitigate the gaps in care. Most experts agree these well-intended efforts will fail, unless the systemic biases that have created and perpetuated the SDoH are also addressed.
CMS will have to do better than introducing a health equity pillar with strategic language. On the other hand:
- YES, for the $226.5 M announced this week via HHS and HRSA for Community Health Worker training; build that segment of the workforce. The fiscal and clinical impact of CHWs is massive, enhancing discharge planning outcomes, enhancing treatment and resource access to the most at-risk patients and populations, which bridges serious gaps in care.
- Develop, fund, and maintain the data exchange infrastructure:
- Expand ICD-10 CM Z codes and approve their reimbursement. I cloud the issue with logic, though reimbursing organizations for the blatant impact of the SDoH and MH on healthcare utilization (e.g., length of stay, ED admissions, readmissions, costs) would greatly enhance revenue coding and capture by healthcare organizations. Organizations will use the codes if there is direct fiscal incentive to do so. GO GRAVITY PROJECT !
- Grow technology programs that directly support my hospital case management colleagues in assessing, referring, and directly connective patients to needed resources, such as FindHelp.
- Expand, Food is Medicine programs nationwide, along with the means to assess and directly link patients to necessary nutritional resources GO FarmBoxRx, FoodSmart!
- Grow funding to Community-based organizations, and safety-net programs, as in community action agencies, neighborhood health clinics, and federally qualified health centers: these are the folks in the trenches!
There was a time when, where CMS went (in terms of reimbursement, programming, and funding) the rest of the industry followed. Yet has this trend shifted? Many have heard me say, “Communities take care of their own”; that is especially true in attaining health equity. Was this latest effort by CMS enough? In time, outcomes will tell the story, but for now, industry stakeholders have stepped up to lead the efforts for their communities, and running ahead of pack.
Your comments are valued so feel free to add them below.
Change is long overdue for this massive maternal health chasm of wholistic health disparities, transcending physical, behavioral, and psychosocial health, and particularly for women of color (WOC)
April 11-17th marks annual Black Maternal Health Week. There will most likely be a flurry of well-intended articles, blog posts and announcements focused on legislation, funding of initiatives and programs, and advocacy. But here’s the lowdown: Black mothers have had higher mortality than White mothers for well over 100 years. They are > 3X more likely to die from pregnancy-related complications and 2X as likely to suffer from mental health issues than their White counterparts. The impact of historical, intergenerational, medical, racial trauma is invasive and enduring. Change is long overdue for this massive maternal health chasm of wholistic health disparities, transcending physical, behavioral, and psychosocial health, and particularly for women of color (WOC)
The recent Commonwealth Fund report on women’s reproductive health reveals how severe the issue remains:
- U.S. women have the highest rate of maternal deaths among high-income countries. The current maternal mortality ratio of 17.4 per 100,000 pregnancies, equals roughly 660 maternal deaths. This earns the U.S. last place standing overall among all industrialized countries.
- A woman’s chance of dying in southern states is 2X greater than those in the north:
- Alabama, Arkansas, Kentucky, and Oklahoma report death ratios of greater than 30:100,000 live births
- California, Illinois, Ohio, and Pennsylvania reported death ratios less than half the figures in those states, <15 deaths: 100,000 live births
Data for WOC is beyond alarming:
- The maternal death ratio for Black women is 37.1:100,000 pregnancies. The number is 2.5X the ratio for white women (14.7) and three times the ratio for Hispanic women (11.8).
- Hispanic mothers were 80% as likely to receive late or no prenatal care as compared to non-Hispanic white mothers.
- A Black mother with a college education is at 60% greater risk for a maternal death than a White or Hispanic woman with less than a high school education.
- Even when WOC verbalize health and mental health concerns to providers, their voice is disregarded:
- WOC are more likely than White women to express their concerns and preferences regarding births though more frequently ignored
- Women with Medicaid report inadequate postpartum care and support, where they are:
- Pressured to have C-sections
- Not scheduled for postpartum visits
- Disrespected by providers due to insurance
- Pregnancy-related mortality rates vary across ethnic groups, yet show a constant disturbing trend:
- Black (40.8%), American Indian/Alaska Native (29.7%), Asian Pacific Islander (13.5%), and Hispanic (11.5%) compared to Whites (12.7%).
- Upwards of 60% of these deaths are preventable. A CDC report, reveals the often avoidable causes:
- Postpartum bleeding (11%)
- Cardiovascular conditions such as Cardiomyopathy (11%),
- High blood pressure (8%),
- Stroke (7%), and a category combining other cardiac conditions (15%).
Maternal Mental Health Awareness Week is scheduled annually for the first week in May, though bears mention. Not treating maternal mental health conditions costs $32,000 per mother-infant pair, totaling $14.2 billion nationally
- Black women are twice as likely as Whites to suffer from perinatal mood and anxiety disorders, and less likely to receive treatment: 40% compared to 20-25%
- Indigenous women have a higher incidence of depression, anxiety, and substance misuse during the perinatal period from 17-47%; Indigenous identity increased the likelihood by 62%
- Migrant WOC are at greater risk for behavioral health issues during pregnancies (e.g., depression, schizophrenia, post-traumatic stress) from the interaction of psychosocial determinants as forced migration plus generalized insecurity associated with experiences as refugees, asylum seekers, and human trafficking victims
Endless data validates WOC’s maternal health mandates. Recent years have witnessed robust action courtesy of fierce voices and tireless work of many entities in the US and around the globe. Their agendas serve as a clearinghouse of efforts. The list below is a starting point of resources:
The “honorary” annual week is valued, but a wholistic health crisis of this magnitude mandates far more than 7 days of attention. Distinct legislation, dedicated and substantial funding at federal, state and local levels is vital. Yet, these efforts are for naught unless the systemic racism and implicit bias that perpetuate this reality are equally addressed. We must:
- Identify, call out, and dismantle systemic racism across macro, meso, and micro spaces
- Develop and implement population-inclusive clinical predictive analytics and algorithms
- Ensure dedicated quality metrics that report the necessary outcomes to drive clinical programming, treatment, and concordant practices
- Shift the academic curriculum to better prepare the interprofessional workforce to provide population-specific care without bias
- Continue to advance the concordant provider-base
- Expand ethnic, racial, and cultural programming, such as reimbursement of community-based Doulas, especially in medically underserved areas.
- Expand access to fertility treatments and address racial disparities in outcomes for IVF. Black women are more likely to have infertility compared to other races, yet the access to treatment is minimal
Data has long validated this epidemic’s emergent state, which has continued to escalate. Maternal wholistic health is a public health emergency of the highest priority. This article is just the tip of the iceberg. I invite those in this care space to post additional resources and information.