Tag: Health equity

Patient Compliance vs. Adherence: Advancing the Health Equity Mandate

Use of the term “compliance” instead of “adherence” by healthcare regulatory entities and organizations, plus practitioners, health systems and their and employees condones the blaming of patients for poor outcomes. It’s time to change this practice!

First, big thanks to all who read my last blog post Health Equity and the SDoH are Not Synonyms. That article has quickly become my top blog post with thousands of views across social media platforms and other news outlets. Ellen’s Interprofessional Insights is free access to all who value its messaging, so please share the link. Now, onto my latest fierce focus. 

I was reminded last week of a long-standing pet peeve: (mis)use of the terms compliance and adherence. I participated in RISE’s Annual Population Health Summit with vibrant conversations int he space about patient engagement. Through a number of sessions there was THAT framing that makes me vibrate with frustration. My brain went into overdrive! 

When will the industry stop blaming patients for treatment inactions? Has there not been enough focus on DEI strategies to enhance practitioner and provider cultural awareness and humility? How much emphasis has there been to advance assessment of health-related social needs (HRSNs) or social drivers of health, patient health literacy, and decreasing biases? (Psssst: Remember, the CMS penalties and Joint Commission standards (TJC) are real!). Despite a resounding YES to the above questions, we’ve got miles to go before we sleep. Use of the term “compliance” instead of “adherence” by healthcare regulatory entities and organizations, plus practitioners, health systems and their and employees only condones the blaming of patients for poor outcomes. It’s time to change this practice!

Compliance Conveys Power Not Partnership

I’m notorious for level-setting and wanted to start with a review of definitions. Compliance refers to regulatory enforcement of applicable requirements whereby organizations and their providers are expected to meet or exceed the defined legal, ethical, and professional standards.Their explicit goal is to reduce fraud, abuse, and waste, with the implicit intent to ensure patient and occupational safety. Yet, there is a concerning power dynamic imposed by this definition as regulatory entities (e.g., NCQA, NQF, TJC) possess legitimate power by virtue of their role in the industry.

Compliance also implies power verses partnership. The term speaks to an assumption that patients must be subservient to a practitioner’s authority, a troublesome concept for this clinical professional. What happens when a patient’s voice is not heard or dismissed by practitioners? What about when a patient doesn’t feel seen?  These situations emerge with increasing incidence across every population, with who are marginalized and minoritized experiencing this reality in unacceptable numbers.

Compliance suggests passive behavior, as when a patient is expected to follow treatment instructions. It may be the patient who is comfortable doing what the physician tells them to, whether take a prescribed medication in a defined dose or follow-up for counseling with a behavioral health provider. Some patients may heed this guidance as the norm, not daring to question their provider, while others will seek to clarify the rationale. This approach should not be surprising in an era where patients are consumers of their care. However, questioning, challenging, or ignoring provider recommendations is too often viewed as a negative. 

Power and misused power yield trauma, whether historical, experiential or event in scope. Acute, chronic, and complex trauma share misused power and/or oppression at their source.  Blaming patients is laden with stigma and accusatory messaging. It gets me wondering how much attention is paid to a patient’s health literacy, language proficiency, or any of their concordant preferences. 


By contrast, adherence is the active choice of patients to follow through with prescribed treatments, while taking responsibility for their well-being. This term signifies that patients and practitioners collaborate to improve their health behaviors toward overall a higher state of wellness. Successful outcomes are achieved through a blend of clinician expertise with patient choice incorporating lifestyle, values, and care preferences. Shared decision-making and personal integrity leverage meaningful therapeutic relationships.

Sync for Social Needs, Z-Codes, Yet Being Out of Sync

I was excited when NCQA, NQF, and the TJC joined the Sync for Social Needs Coalition. Yet, these entities present as out of sync with their views on how to best assess and address exactly what drives patient motivation and engagement in treatment. NCQA still uses the term adherence on their resource pages and metrics. TJC echoed emphasis on patient activation and adherence in recent issue briefs.

My beloved Z-Codes are not so in sync either. ICD-10-CM Z codes for Patient Noncompliance were expanded in 2023 to my disappointment. To be fair, I’m a member of the Gravity Project and tout their work at every opportunity. However, I took a brief break from my involvement to finish my Doctoral Culminating Project. The mantra, you snooze, you lose applies!

Z-Code Z91.1 of patient noncompliance with medical treatment and regimen made me shiver. How is this concept objectively evaluated in the current care climate? Hearing colleagues refer to “non-compliant patients” always felt subjective. The terminology stirred thoughts of misbehaving children or those unable to follow traditional societal norms. 

My clinical training aligns with psychodynamic theory, thus there are always reasons for all behaviors, whether conscious or unconscious. This approach explains why a person may present as unable or unwilling to follow medical treatment. If we don’t ask why, we can’t properly assess the reasons for these behavioral manifestations. Expanding these codes gave the industry license to label patient actions as “noncompliance” with their dietary regimen and medical treatment. Caregivers of patients are also subject to these same biasesfor their “noncompliance “with an expansive list of codes under Z.91. These codes can be viewed here.

This terminology use is shocking given how the workforce is readily cued to manage their biases, stay informed of microaggressions, and participate in continuous learning to decrease missteps. Training on cultural awareness to promote patient engagement and satisfaction with care is emphasized at every turn. Yet, I am disappointed that practitioners are empowered to code, and thus blame, patients and caregivers for treatment disparities and misunderstandings.

Activating Change

Industry prioritization of health equity mandates a cultural shift in treatment language and perspectives. Here are tangible recommendations:

1. Shift the narrative and power dynamic: Practitioners and providers must shift from viewing compliant and “obedient” patients to persons provided the respect and space to partner in their treatment decisions. Autonomy and self-determination remain enduring ethical principles and amplify attention to cultural perspectives.

2. Coping with the human condition is universal: Most patients and their caregivers experience fear and anxiety about their health conditions and those of their loved ones. A majority worry about diagnosis, prognosis, and quality of life. Everyone uses some defense mechanism to cope or not (e.g., denial, isolation, projection, displacement). The reality of the health experience often occurs without warning, and usually when least expected. We must give people the grace and space to cope with it.

3. Engage to understand patient and care giver rationale: To embrace cultural awareness and humility we must seek to understand patient and caregiver behaviors. We must eliminate implicit biases rather than empower them through quality metrics and measures; “these biases reinforce blame on the patients rather than look to the system and/or the competencies of the clinicians”; big nod to my friend Michael Garrett for this quote!

4. Assess for Psychosocial Needs: This arena is a top priority for organizations and most I know are on the case to integrate reflective screening tools into their efforts. I appreciate that far more resources are needed for all of those who need them. However, let’s make sure the right team members are employed for assessment and referral of patients, including community health workers, case management assistants, and health service coordinators. The outcomes are clear about their merits to assess across the touchpoints of care for:

  • Health and digital health literacy
  • Cultural preferences for treatment (e.g., medication, provider gender)
  • HRSNs, financial, and other impediments to care (e.g., co-pays, medical debt, lack of family support, isolation, transportation, incarceration, techquity) 

5. Use Non-Judgmental Communication: It is critical we set an inclusive tone to care, including but not limited to:

  • Maintain an affirming presence to establish trust 
  • Ask the patient to verify their gender and pronouns 
  • Ask the patient to verify their race and ethnicity
  • Ask the patient to identify their family or support system, regardless of blood relation
  • Demonstrate empathic and reflective listening 
  • Respect client autonomy by allowing the person to speak 
  • Empower patient through use of open-ended questions, such as, ‘What matters most to you?” or “What can I do for you today?”
  • Respond, clarify, and confirm, instead of reacting
  • Honor the patients religious and cultural beliefs, values, and choices

(Fink-Samnick & Garrett, 2023) 

Unconditional respect between patients and providers is difficult, but not impossible. Little will change toward engaging patients in their needed care until we stop blaming them for the industry’s shortcomings.

Health Equity and the Social Determinants of Health Are NOT Synonyms

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. 

I delayed writing this blog to not compete with a recently published article in CMSA Today on The Social Determinants of Health: Case Management’s Next Mandate. It’s a quick 5-minute read if you haven’t gotten to it yet. However, that additional week gave me time to review another important and slightly longer read, the National of Academies of Science, Engineering, and Medicine report, Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity 

Report Overview and Missteps

This well-intended report from the National Academies highlights the mandate for macro-level oversight of three disparity domains, as reflected in the title. There was affirmation how the social determinants of health and mental health (SDoH and MH) and the policies that shape them contribute to hindering and advancing health equity. Valuable recommendations included:

  • Creating a permanent federal body responsible for improving racial, ethnic, and tribal equity across the federal government
  • Development by Congress of a score card to assess the impact on health equity of all proposed federal legislation in the future, and
  • Having Federal agencies conduct an equity audit of their current policies. 
  • Collecting more accurate and complete population data for minoritized communities; those social (racial) groups that are marginalized or persecuted due to systemic oppression. 
  • Improving coordination among federal agencies
  • Supporting better inclusion of community input, and 
  • Increasing federal support and access for state and local programs.

These recommendations were sound, as the communities highlighted all face considerable obstacles in accessing optimal physical and behavioral health. Yet, the report suffers from two common flaws that I often identify when reviewing published works on this topic:

  1. Aligning health equity attainment only with the SDoH and MH, and 
  2. Viewing only racial and ethnic populations in the context of the discussion.

Health Equity and the SDoH Are Not Synonyms

Few things annoy me more than short-sighted views of the healthcare horizon in the context of our health equity challenge. I get especially irritated when health disparities are attributed to the SDoH alone. For example, I often hear presenters discuss high mortality rates for minoritized populations and attribute these poor outcomes to poverty and low socioeconomic status, unemployment, and lesser education. Maternal mortality for Black Women is >2.6 X that of White Women, though this particular data point was independent of income, education, or other elements commonly associated with health disparities. 

These faulty views impede accurate comprehension of the full scope of factors obstructing health equity, including systemic and structural racism, implicit and explicit biases, and the political determinants of health (PDoH). This erroneous perspective perpetuates generations of historical, experiential, and other event traumas endured by these populations. Patients continue to be blamed for their poor health outcomes rather than the system (and its providers) that created the chasms in care to begin with. 

Inadequate data to reflect minoritized populations has led to a risk-management ripple-effect. Faulty algorithms have been identified across clinical decision-making and interviewing models leading to inaccurate risk assessment, treatment recommendations, and medication dosages. Poor operational and fiscal outcomes intersect with quality and safety concerns, especially when the data used does not accurately reflect the clinical needs of the population. 

Health Equity Includes More than Race and Ethnicity

Achieving health equity involves taking dedicated action to improve the access, quality, and experience of healthcare for all individuals, populations, and communities. There is no doubt that race and ethnicity are key constructs for research attention and action, with abysmal morbidity and mortality rates. The National Academies report notes:  

  • Life expectancy for non-Hispanic Whites at 78.9 years of age compared to 75.3 for Blacks, and 73.1 for the American Indian and Alaska Native populations.

However, other marginalized populations face equally worrisome barriers to equitable care access and treatment. Of equal importance are gender orientation, age, and individuals with physical, cognitive, developmental, and mental health disabilities, to name a few areas. These populations are too often left out of health equity discussions:

  • Sexual and gender minority (SGM) populations have a higher incidence than non-SGM of developing chronic diseases (e.g., asthma, arthritis, diabetes, kidney disease, hypertension, cardiovascular disease, heart attack, stroke, and chronic obstructive pulmonary disease (COPD)), and more frequently deal with barriers to care from discrimination, let alone cost.
  • People living with disabilities (PLWD) have poorer health than the general population and are at a greater risk of injury and of developing non-communicable chronic diseases and age-related health conditions at earlier ages. 
  • Rampant gender disparities present in pain management, especially for those who identify as women. They experience “gendered treatment” across healthcare settings and with symptoms devalued or dismissed by their healthcare providers. This study’s results were also independent of socioeconomic status, education, or other health-related social needs.

The President of the National Academy of Medicine, Dr. Victor J. Dzau is correct that “Addressing the nation’s racial and ethnic health disparities is an imperative for the medical community.”; I would also add the priority for behavioral health given the current societal demand; after all, there is no health without mental health and visa-versa. However, efforts that limit health equity strategies to racial and ethnic disparities are short-sighted. Successful diversity, equity, and inclusion imperatives require the voice of every societal stakeholder across the entire cultural schema. 

Health Equity Actions Advance

Attaining health equity involves dedicated action to improve the access, quality, and experience of healthcare overall. This translates to intentional work by everyone, from those in data analysis, and learning and development, to persons specializing in process improvement and data measurement. This means:

  1. Developing quality metrics for health plans, health systems, and other entities that focus on more than reactive, short-term return on investment metrics, such as readmissions, patient engagement, and patient satisfaction. These antiquated data points only blame patients for poor outcomes through use of language such as “non-compliant”, rather than put accountability for change in the hands of providers. 
  2. Ensuring quality improvement efforts reduce unnecessary care utilization (e.g., ED visits, hospitalization), while simultaneously increasing access to preventative and primary care, behavioral health, and specialty care; this means adding concordant providers and approaches to care, which has been addressed in prior blog posts.
  3. Shift case management back to a proactive vs. reactive model; discharge planning is not the sole priority. Instead, case management competencies must highlight swift assessment of patients and their support systems, care coordination, interprofessional collaboration, effective communication, and outcomes management, while heeding professional ethical and compliance standards.
  4. Educate policy makers on inclusive health equity frameworks such as by Peterson et al. (2020). This robust framework accounts for equity and justice at the core of health outcomes, multiple and interacting spheres of influence, and a historical and life-course perspective (e.g., historical, experiential, developmental traumas). 
  5. Reinforce a sense of belongingness by everyone, especially persons from underserved communities. All patients and their families should feel seen, heard, and safe in the healthcare sector. This outcome can be measured by patient reported outcomes measures (PROMs), employee satisfaction and engagement surveys, and methods that involve analysis of these measures through demographics of race, ethnicity, and gender, sexual orientation, gender identity, physical and developmental disabilities, and socioeconomic status.

The Call to Action

“Our industry achieves the highest level of health for all persons, only when all voices are included. Communities that commit to health equity make all persons feel valued, and do so via concerted and ongoing attention. It is only through this all-encompassing effort that avoidable inequities are identified and addressed, historical and contemporary injustices are eliminated, and healthcare disparities are mitigated.” (Fink-Samnick & Garrett, 2023). 

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. All populations deserve better.

The Case for Diversity in Health and Behavioral Health Professions is More Than Powerful: It’s an Interprofessional Mandate

The face of the current health and behavioral health workforce fails to mirror the workforce it cares for. The recent SCOTUS decision will only further negate cross-sector efforts to attract, admit, train and, sustain the inclusive workforce patients need. What must happen to mitigate this massive gap in care?

I am a fan of the Commonwealth Fund’s issue briefs, and the recent one on The Case for Diversity in Health Professions Remains Powerful was especially significant. The messaging was in direct response to the latest SCOTUS decision on Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. For those who missed it, this decision removed “race-conscious affirmative action” in undergraduate admissions. This decision is poised to drop Black and Hispanic admissions by at least 10%, and strike a blow to diversity, equity, and inclusion (DEI) in education. The ripple-effect of this decision across all historically vulnerable populations was made clear in GLAAD’s post-decision statement: 

 “This decision inaccurately and unfairly limits access to the American dream, and drags our entire country backward, upending decades of precedent and progress. Equity for Black Americans and all people of color, including LGBTQ people, is essential to our democracy, economy, and future. This decision could also open the door for challenges to DEI practices in business settings and it is critical that companies and educational institutions respond with loud commitments to continue best practices for inclusion.”

Gaping wholistic health disparities already limit access to necessary physical, behavioral, and psychosocial health. The face of the current health and behavioral health workforce fails to mirror the workforce it cares for. The recent SCOTUS decision will only further negate cross-sector efforts to attract, admit, train and, sustain the inclusive workforce patients need. This action has great potential to inflict greater harm to a population already dealing with historical, experiential, developmental and other traumas. What must happen to mitigate this massive gap in care?

The Current Discordant Reality

I was educated and trained at a time when practitioners were often taught that anyone could work with anyone; I fought the opposing views for years. However, the research to support concordant care is equally compelling. I feel strongly that we must teach and emphasize the importance of cultural humility and work to eliminate implicit and explicit biases in practice. But, we also have an ethical obligation to be sensitive to the cultural nuances that come with caring for others. Every patient deserves to feel safe and a sense of belonging in the context of their care and treatment.

Academic programs across every discipline are working overtime to fill the massive void of practitioners available to treat underserved communities and their populations. Conclusive data validates how patient-provider concordance makes a difference in the quality of patient engagement, trust, and satisfaction. Patients do better in treatment when they feel that their providers and practitioners understand them and look like, and this reality transcends the cultural schema. However, current workforce demographics fails to ensure any level of concordant care.

A recent report  of medical residents yielded: 

  • Black men make up less than 3 %of all physicians
  • <1 percent identify as American Indian, Alaska Native, Native Hawaiian, or other, Pacific Islander

For active physicians:

  • Persons who identify as men comprise a majority of the physician workforce: 63% vs. 37% (women) 
  • Persons who identify as women comprise >50% of the medical specialties focused on children, women, and families (e.g., reproductive health, pediatrics, neonatal and perinatal medicine, and child and adolescent psychiatry). 
  • 64 %: White
  • 20.6 %: Asian 
  • 6.9%: Hispanic, and 5.7 %: Black or African American. 
  • Barely 1 %: multiple races and non-Hispanic
  • < .3%: American Indian or Alaska Native or
  • .1% Native Hawaiian or Other Pacific Islander

Data for mental health practitioners yield equally concerning results, particularly in light of the high demand for care. A survey >37,000 mental health professionals yielded abysmal numbers that fail to reflect the diversity of populations requiring intervention and treatment:

  • 74.2%: White  
  • 7.9%: Black or African American 
  • 7.9%: Hispanic or Latino.
  • 3.1 %: Asian
  • .7%: American Indian or Alaska Native

There are insufficient health and behavioral health professionals trained to work with the LGBTQIA++ community, and ensure patient safety, trust, and satisfaction with their care. 

Persons with Disabilities have limited representation in the healthcare workforce. A report from 2022 revealed:

  • 7.9% employed within healthcare with 4% as practitioners and 4% in healthcare support roles

The industry has miles to go toward ensuring a concordant health and behavioral health system and workforce that matches the face of the population it is entrusted to care for. How else can patients feel seen, heard, and assured of the care they deserve?

Advancing Action

I rarely post dramatic data without offering ways to mitigate the gaps in care presented. Considerable action across industry sectors is being dedicated to attaining a more diverse health and behavioral health workforce. The efforts in play comprise an exhaustive list, but a few novel ones are listed below. Add others that you may be aware of in the comments section at the end of this post.

The Smallest Advocacy Actions Can Yield the Greatest Reward

My recent travels reminded me how much satisfaction can be gained by advocacy on behalf of a larger group of individuals.

The universe provides us interesting lessons, and usually when we least expect them. That mantra about the journey being as meaningful as the destination applies to this blog, but in a different way than you might expect. While the theme of this post alludes to the importance of equity and response to trauma, it is not my traditional fierce messaging. Instead, this post offers my reflections on the rewards that can come from contributing to the greater good.

Where it Started

This last month has been full of conference travel, with my usual array of presentations and panel discussions. I was honored with the publication of my fifth book (The Ethical Case Manager: Tools and Tactics) and also inducted as a Case Management Fellow (FCM™) by the Case Management Society of America (CMSA), and the first social worker to do so. These accolades are important career milestones for which I’m grateful. Yet, these milestones paled in comparison to one experience that occurred around the same time. That event reminded me how much satisfaction can be gained when one small action is taken on behalf of a larger group of individuals.

These past weeks saw travel challenges for much of the population. The experiential trauma for all traveling during this timeframe was palpable, and due to events that were usually beyond each person’s control. This loss of power left travelers reeling. There were flight delays courtesy of extreme weather conditions, workforce shortages, and flight cancellations. There was even a substation fire that prompted a lengthy hold on flight departures and arrivals at one large international airport.

Who sat at airports for endless hours or days, in hopes of getting to their anticipated destination? How many slept on airport furniture or even floors? Who missed conferences, business meetings, family, or other long-awaited celebrations? Who missed flight connections by a matter of minutes? How frustrating to see your connecting flight at the neighboring gate upon landing, but unable to sprint off the plane quickly enough to get on board!

Where it Went

I was among the lucky ones. While several of my flights were delayed, I always got to my destination. Yet, the experiences for one flight impacted me greatly. I was heading home from a conference in Miami. That event fell during the initial, and often chaotic, June vacation week. The flight was loaded with travelers embarking on international trips, and catching connections at my destination, Dulles Airport in Herndon, Virginia. 

A large band of thunderstorms delayed our departure from Miami by 90 minutes and threw passengers into a panicked state. Some individuals had planned their trips for months, while others had sudden family and business emergencies to manage abroad. Even once we were in the air, flight attendants worked continuously to calm upset passengers throughout the aircraft and contact various airlines to hold connecting flights, as possible. Some of these flights were also delayed, which somewhat eased the worry of already tired and, in some cases, traumatized passengers.

Upon landing at Dulles, an announcement was made by the flight attendant to allow travelers with connecting flights to disembark first. I had a sneaking suspicion that this action would be hard to implement and wasn’t wrong. Everyone stood up to grab their bags and deplane. Here was my opportunity to help! I was close to the front of plane and in a pivotal position to be an enforcer of this one simple and logical request. Little did I know that I had a collaborator seated nearby who was equally committed to doing the right thing, and for all passengers.

My collaborator sat directly across the aisle from me, and spent most of the trip consoling the passenger next to her. This person was visibly upset about the disruption to her travel. The flight attendants were able to confirm that this passenger’s connection flight was three gates away and being held for her arrival. Yet, her worry remained at a fever pitch.

My collaborator and I stepped up simultaneously and into action. We realized that some people might not feel empowered to get off the plane, especially those persons sitting toward the back. We directed passengers who did not need to run for a flight to stay in their seats. There were some interesting expressions and explicatives shared, though everyone ultimately got our drift and pitched in to support the efforts. Within minutes, close to 180 passengers successfully (and gratefully) deplaned. My aisle-mate and I were among the last passengers to leave, and with appreciation of the flight crew.

How it Mattered

I slowly walked to the airport shuttle, then turned around to see my collaborator behind me. We smiled at each other and chatted about our actions. We treated others as we would want to be treated if in the same situation. We advocated for the human condition, which was what I was trained to do as a board-certified case manager and clinical social worker. She and I were also in agreement about one key takeaway from this experience, which more than equaled, if not exceeded any of my recent accolades. Our advocacy takes all forms. Yet, even the smallest advocacy actions can make the biggest difference to others, and in turn, can provide us the greatest reward.

Part 2: Wholistic Health Equity Determinants and the LGBTQIA++ Community

This Part 2 post continues exploring the pervasive impact of Wholistic Health Equity Determinants (WHED) on the LGBTQIA++ community. Focus is on the rising incidence of trauma and mental health conditions across the community and the expanding advocacy, funding, as well as resources to mitigate the WHED.

I appreciate the buzz about my last blog; it’s a quick read if you missed it. To catch you up, the LGBTQIA++ community face pervasive Wholistic Health Equity Determinants (WHED): SDoH, SDoMH, PDoH, and the systemic racism that perpetuates them. Discrimination, dismissal, and rejection trigger trauma across every demographic, and intensify integrated health incidence across this population. This Part 2 post explores the unprecedented exacerbation of behavioral health conditions and escalation in mental illness for the the LGBTQIA++ community. Additional focus is placed on novel resources to mitigate the physical, behavioral, and psychosocial health disparities faced by this population.

The Behavioral Health Landscape

     Let’s be clear, the LGBTQIA++ community is a marginalized population with morbidity and mortality rates that are worse than other groups. Increasing attacks on the community’s legal rights have amplified the impact of historical, experiential, and event traumas for the population. 

The following data sources span The Trevor Project’s 2023 U.S. National Survey on the Mental Health of LGBTQ Young People, the 2020 National Survey on Drug Use and Health, and other research.

Suicide

There has been a dramatic uptick in suicidal ideation and gestures among LGBTQIA++ individuals, especially for the community’s youngest members:

  • 41% considered attempting suicide:
    • 46%: Ages 13-17 and 34%: Ages 18-24
    • Of those who attempted suicide: 
      • 17%: Ages 13-17
      •   9%: Ages 18-24
      • 22%: Native/Indigenous 
      • 18%: Middle Eastern/N. African
      • 17%: Multiracial
      • 16% Black
      • 15%: Latinx
      • 11%: White
      • 10%: Asian American/Pacific Islander

Mental Health and Access to Care

The incidence of mental health faced by the community is alarming with higher rates for depression and anxietycompared with non-community members. The prevalence of post-traumatic stress disorder impact upwards of 47% of the community.

Yet, the rates for mental health realities faced by LGBTQIA++ youth concern me greatly:

  • 67%: symptoms of anxiety
  • 25%: symptoms of depression
  • 56% who wanted mental health care were unable to get it:
    • 47%: afraid to talk about their mental health with someone else
    • 41%: didn’t want to get their parent’s/caregiver’s permission
    • 40%: afraid that they wouldn’t be taken seriously
    • 38%: couldn’t afford it
    • 27%: were not out about their authentic self and were afraid of being outed
    • 23%: didn’t feel they would understand their sexual orientation or gender identity
    • 20%: parent/caregiver didn’t allow them to go
  • <50% of transgender and nonbinary youth found their school to be gender-affirming
  • 30% said their mental health was poor most of the time or always from anti-LGBTQ policies and legislation.
  • Nearly 66% affirmed how hearing about potential state or local laws banning people from discussing LGBTQ people at school made their mental health worse.

Persons with Disabilities

Members of the LGBTQIA++ community have a higher likelihood of disabilities, whether physical, cognitive, or intellectual. Incidence is upwards of 40% of persons, though fewer of these disabilities are often expressed by individuals or formally identified.

As an already marginalized group, individuals with disabilities may feel “unseen” and experience more profound stigma and discrimination. Cumulative effects of this marginalisation can occur over the life course, with older members of the community experiencing higher rates of disability, depression, anxiety and isolation than the general community, and decreased social support. They are less likely to advance academically, with fewer persons attending college or attaining beyond a 2 or 4-year degree.

Transgender, non-binary, or gender non-conforming people with disabilities can often feel silenced. Abundant literature affirms they are more likely to experience chronic illnesses, including cardiac disease, high blood pressure, high cholesterol, diabetes, stroke, arthritis, and asthma compared to persons living without disabilities.

Substance Use

The community experiences substance abuse at higher rates than their heterosexual counterparts:

  • LGB Adults: 2X as likely
  • Trans Adults: 4X as likely

21.8%: Diagnosed with an alcohol use disorder vs. 11% of the general population

Advocacy and Action

Advocacy and action have ramped up for dedicated funding, legislation, and program development. Educating industry stakeholders is vital, as is ensuring mentoring and support for LGBTQIA++ youth, adults, and their families. Registries of providers, practitioners, and treatment specialists who offer concordant care are essential. Here is a list of novel community-focused efforts:

  • The Department of Housing and Human Development has launched a new LGBTQIA++ Youth Housing initiative. HUD will partner with local communities, service providers, and young people directly impacted by residential insufficiency to address barriers to housing and shelter access. The recent press release lists further details
  • GLADD provides a clearinghouse of population-specific resources for advocacy, legal, and other general information across the life span. Military members and veterans can access specific linkages to various entities such as OutServe and the Service Members Legal Defense Network.
  • The Human Rights Campaign strives to advocate and promote equity for all persons within the movement. Their massive resource database encompasses topics to empower allies and other community stakeholders from coming out to maneuvering college, elections, hate crimes, health and aging, parenting, religion and faith, and workplace support. 

HRC’s Foundation supports the National LGBTQIA++ Health Education Center, which provides educational programs, resources, and consultation to healthcare organizations to optimize quality, cost-effective care for the population. Accessible webinars span topics as behavioral health, population-based health, trauma-informed care for Trans and Gender Diverse Patients, reproductive health.

  • NAMI offers general guidance on mental health issues faced by the community, and considerations for seeking LGBTQIA++-competent care.
  • Rainbow Labs in Los Angeles, addresses the bullying, isolation, and lack of support often faced by Queer and Gender non-conforming youth (QGNC). The organization provides mentorship, support groups, and linkage with safe individuals, advocates, and programs. One Bold Summer is a free 8-week summer mentoring initiative for QGNC youth (ages 12-18) that pairs QGNC youth with mentors. 
  • SAGE is the largest and oldest U.S. organization dedicated to improving the lives of LGBTQIA++ older adults. The group has been on the forefront of advocacy for elders, quality of long-term care, housing, and other resources. Their National Resource Center on LGBTQ+ Aging hones in on the unique needs of community older adults such as caregiving, elder abuse and neglect, benefit programs, financial, and other health-related social needs.  
  • SMYAL is among a growing number of locale-based housing programs that ensure safe, LGBTQ-affirming support, through tiered residential options: transitional housing, extended transitional housing, and rapid re-housing. Residents can access a range of courses and community engagement opportunities including nutrition and cooking classes, financial literacy, healthy relationships and communication, and resume workshops.
  • The Trevor Project provides 24/7 information, support, and resource connection for LGBTQIA++ Youth around the world. Mechanisms allow for immediate access to trained counselors via call, text, or chat, and linkage to an international community for LGBTQ young people

What’s Next?

I have been a fierce ally of the LGBTQIA++ community for well over 45 years, with countless family, friends, and colleagues in this space. Despite efforts to address the massive WHED faced by the community, innumerable challenges remain. The list of resources in this post is a broad swipe of efforts on the move.

Blog readers are encouraged to contribute resources as they know of them. The work to mitigate WHED for this population will take the collective and concerted action of us all!

New Book Frames a Vivid Ethics Spectrum for the Interprofessional Case Management Workforce

Case managers strive to be ethical, and can recite the industry’s ethical tenets of autonomy, beneficence, fidelity, justice, and nonmaleficence by heart. Yet, too often case managers get caught in the crosshairs. Enter, Dr. Ellen Fink-Samnick with a timely resource and Amazon’s #1 best seller (Medical Ethics, Nursing Administration & Mgmt.) for all professional stakeholders: student, novice and more seasoned case managers, consultants, and those in leadership roles.

Ethics has long been viewed as not black and white, but rather varied shades of gray. However, these interesting times mandate a novel stance. Ethics now comprise a spectrum of vivid colors that reflect its fierce disruptions to practice, and for every member of the health and behavioral health workforce. Managing this intense reality is a constant struggle for all practitioners, especially those in case management. My latest book and Amazon’s #1 Best Seller in Medical Ethics offers clear guidance; enter The Ethical Case Manager: Tools and Tactics

Case management’s workforce faces many accountability challenges not experienced by other professions. First, case management is an umbrella profession comprised of varied disciplines (e.g., counseling, nursing, occupational therapy, and social work). Each discipline has a distinct code of ethics or professional conduct, as well as dedicated standards of practice. Let’s add another layer of complexity that includes the over 25 case management-related credentials for individuals (e.g., ACM, CCM, CDMS, CMGT-BCTM, CRC), those for organizations (e.g., NCQA, URAC)and their unique requirements. Of course, there are also a lion’s share of professional associations across the industry. The landscape gets even more precarious when including the hierarchy of case management roles that span community health workers, case management assistants, and community based case managers, to board-certified case managers, and those in leadership positions. 

The question beckons: Where should your ethical compass point? The range of established resources of guidance defined by each of the above entities makes the answer to this question challenging to answer. It also yields two confusing conundrums for the workforce:

  1. Defining the ethical and legal parameters for case management practice, and 
  2. Reconciling these parameters with employer policies and procedures across the industry.

Here’s where, The Ethical Case Manager: Tools and Tactics comes to the rescue. The book’s content is written for an interprofessional audience that spans the educational spectrum of degrees held by those in the field. This approach provides a context for accountability, while addressing the most complex ethical dilemmas to date. Attention is paid to workplace bullying, digital healthcare innovation, management of implicit biases, microaggressions, health equity and inclusion, plus interstate practice, and other population health situations. The pandemic’s wrath is woven within chapters where relevant. Didactic knowledge is blended with Federal and state regulations, innovative models, practice templates, and dedicated resources.

Each of the book’s 10 chapters includes real-life case scenarios and contemplation questions that allow learners to dig in and apply the content. 20 Ethical Tactics provide tangible touchpoints for learning. Every reader will reap their own reward, from students, to new or more seasoned case managers, consultants, as well as those in leadership roles.

The Ethical Case Manager’s 318 pages encompass the most vital areas for case managers:

  • Section 1: Essentials of Ethics
    • Chapter 1: Terms and Definitions
    • Chapter 2: Established Resources of Guidance
  • Chapter 3: The Value Proposition for Ethical Case Management
  • Section 2: Realities of practice
  • Chapter 4: Population-based Practice
  • Chapter 5: Diversity, Equity, Inclusion, and Justice (co-authored with Michael Garrett)
  • Chapter 6: Workplace Bullying
  • Chapter 7: Health Information Technology
  • Chapter 8: Interstate Practice
  • Section 3: Activation of Ethical Decision-making
  • Chapter 9: Enduring Models
  • Chapter 10: Case Scenarios and Direct Application
  • Epilogue

The Ethical Case Manager: Tools & Tactics will be your primary resource, whether you seek to:

  • Educate students
  • Onboard new staff
  • Benchmark ethical practice
  • Resolve ethical dilemmas
  • Guide compliance practices 
  • Ensure successful fiscal, clinical, and operational outcomes 
  • Employ ethical decision-making models
  • Leverage interprofessional teams
  • Inform individual practices

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The Ethical Case Manager: Tools and Tactics is only available on Amazon and for a special introductory price of $43.18. Pricing increase to $69.99 on 5/31/23.

Attending the upcoming Case Management Society of America Conference in Las Vegas? You will have access to 2 exciting book signing events: 

  • 6/27/23-Pre-Con, Telehealth 2024: Advancing Case Management’s Practice Proficiency, 2:15-3:15 PM
  • 6/29/23-Exhibit Hall book signing at the Case Management Institute table, 11 AM to 2:30 PM. Discounted rates, bulk orders, and bundled specials will be available! 

#ethicsmatter

#ethicalCM

Trauma 4.0: 30-Day Landscape of the Post-Roe v. Wade Era

Providers, practitioners, patients, and their supports have long dealt with public scrutiny over the decision to terminate an unintended, unviable, if not potentially life-threatening pregnancy. Yet, amid the post-Roe v. Wade era, it has become tougher to receive and render necessary care; a new dimension of trauma is being unleashed for all involved.

Roe v. Wade was overturned one month ago. The flagrant assault on women’s health and their reproductive rights is now at full throttle. My blog post, Trauma Amid Roe v. Wade Despair, addressed the historical, manifesting, and enduring trauma experienced across society from this new norm. Providers, practitioners, patients, and their supports have long dealt with public scrutiny over the decision to terminate an unintended, unviable, if not potentially life-threatening pregnancy. Yet, this intimate choice was a guaranteed right under the law for almost 50 years, that is until June 24th, 2022. 

I introduced the hashtag, #Therewillbetrauma, which has resonated loudly across the globe. It has joined other entries on social media related to this topic, including:

#abortionishealthcare

#freedomofchoice

#mybodymychoice 

#reclaimRoe

#reproductiverights

#righttochoose 

#Roe43

There has been an outpouring of mobilization this last month to counter the Dobbs v. Jackson decision that overturned Roe v. Wade. Struggles to ensure necessary care for women in need have been fierce with ongoing efforts to craft new abortion and reproductive rights legislation. More vulnerable populations, such as women of color, transgender men, nonbinary, and gender-nonconforming persons. and those living in poverty were disproportionally impacted prior to Dobbs v. Jackson; their access to appropriate healthcare often limited. A recent Kaiser Family Foundation analysis identifies these populations are more likely to obtain abortions, yet have limited access to health care, and face systemic inequities that make out of state travel for abortions more difficult compared to White counterparts.

Recent events have occurred amid these struggles that reinforce the impact of trauma’s wrath. Each packs a fierce intensity to challenge ethical tenets across health and behavioral health care. Patient autonomy is compromised, as is beneficence, fidelity, justice, and non-maleficence. What happens when “do no harm” is the antithesis of reality for those reconciling their intimate right to choose, and the inability to do so?


Ethics Matter

#Ethicsmatter is another of my popular hashtags. The following news stories demonstrate how little ethics matter to far too many. Each event activates a trauma response that sends my cortisol levels into overdrive. I am a seasoned clinical professional, but also a woman working hard to maintain balance amid a range of emotions, from anger and frustration, to sheer rage:

  1. Within weeks of Roe v. Wade being overturned, a horrific story surfaced. A 10 year old in Ohio, had been sexually assaulted and raped by a 27 year old man, resulting in a pregnancy. At 6 weeks and 3 days of gestation, the child was denied an abortion in her home state due to the Dobbs v. Jackson decision; she was forced to travel across state lines to receive appropriate health care. The physical and psychological trauma from rape is unthinkable. The thought of a rape victim being forced to carry a resulting pregnancy to full-term against her choice is reprehensible; for a 10 year old child, it is unconscionable. This is trauma.
  2. The 10 year old discussed above was referred by her physician to an OB/GYN in Indiana to terminate her pregnancy. The treating physician, Dr. Caitlin Bernard, has subsequently been harassed and threatened by the public, as well as Indiana’s attorney general; her medical license is now under scrutiny. Reports validate Dr. Bernard complied with state and local laws, such as existing HIPAA privacy rights laws for treating a minor, reporting the case to child protective services, and other regulations. Despite acting with beneficence, fidelity, non-maleficence, and egal due diligence, Dr. Bernard faces “reputational harm and emotional distress”. This is trauma.
  3. Marlena Still and her husband, Abie DeSilva live in Texas and were excited about their pregnancy; the couple have a toddler and had tried conceive a second child for some time. During a routine office visit at 9 weeks, doctors informed the couple that there was no heartbeat, and thus, no viable pregnancy; a fetal demise was their new norm. The emotional intensity of their baby dying in utero was unthinkable and traumatic enough. Yet, this tragic situation took an even, more tragic turn. The events that followed were antithetical to “do not harm”:
  4. Marlena was forced to carry a dead fetus for 2 weeks: This is trauma.
  5. Marlena requested a Dilation and Curettage, also known as a D and C and the traditional care following a miscarriage. Her physician refused to do the procedure, citing the new Texas anti-abortion law as the reason. She noted the patient must have a transvaginal ultrasound before further consideration of the procedure. This is trauma.
  6. Marlena endured this invasive diagnostic procedure, plus, then was forced to hear the words no parent experience, and more than once: “your baby is dead”: This is trauma.
  7. After the second ultrasound, Marlena’s OB/GYN still refused to provide clinically indicated care putting her at grave clinical and emotional risk. The patient endured, yet another, ultrasound: This is trauma.
  8. The literature notes profound risks associated with fetal demise and from carrying a dead fetus for an extended period of time: hemorrhage, infection, infertility, organ failure, mortality. The psychological impact of being forced to experience this reality is unacceptable: This is trauma.
  9. Marlena found another physician to do the D and C procedure. This denial of clinically appropriate miscarriage care and treatment is unethical and immoral. This is trauma.
  10. The couple are considering leaving their home state of Texas, their family and support system. They have also opted to not try and conceive another child. Marlena is fearful of being unable to access appropriate care should she have another fetal demise. She is not prepared to put her life in jeopardy and risk leaving her daughter without a mother and husband without a life partner. This is trauma.
  11. The reality for Elizabeth and James Weller of Texas is gut wrenching and almost too much for, even, this author to fathom. At 18 weeks pregnant, her water broke. Given the length of this blog post, those interested can review the heartbreaking events in an article on NPR. They tell a horrific story no person should have to endure: traditional obstetric care amid a medical emergency obstructed due to state law, a patient’s life at risk as she is forced to endure medical and emotional trauma while awaiting “fetal death”, a physician caught in a legal quagmire and unable to practice medicine in a way that prioritizes, “Do not harm”. This is the grim reality which has been created; THIS IS TRAUMA.

The Current State of Trigger Laws

 The emergence of trigger laws banning abortion has been swift. An interactive map of current laws across the nation appears on Governing.com. As of this writing, abortion is illegal in 10 states, though 13 others limit access. Idaho, Tennessee, and Texas will join the state bans in place as this article is published, on July 24th, 2022; Arizona and Georgia will follow in the coming months with a growing number of states curbing women’s reproductive rights. Providers may refuse to participate in an abortion procedures in 45 states. Those practitioners supporting reproductive rights are being threatened at every turn. They are becoming more reluctant to provide necessary care and treatment to women experiencing fetal demise, or where the termination of a pregnancy is clinical indicated; fear of legal reprimand and sanction may supersede patient care. Waiting periods for abortions are advancing, as are efforts restricting all types of abortions: those received across state lines, telehealth procedures, and mail access to medications that induce miscarriages. The reproductive rights scene for women, their families, and all providers who care for them, is becoming scarier by the minute. This is trauma.

Advocacy Matters

As the first 30 days of our post-Roe v. Wade era draws to a close, advocacy continues to be the antidote. The resource listing from my initial blog post on this topic is posted below for ease of access. Engage in action as you can and vote:

It is unclear what the next 30 days will bring, though there is one certainty. Trauma is now its own epidemic, and will only intensify. Amid the battle to fight for reproductive and women’s health rights, there is, and will continue to be, trauma. How much will be determined by ongoing advocacy toward action.

Income Insecurity Impacts Access to, Affordability of, and Outcomes for Men’s Wholistic Health

Men’s access to, use and affordability of physical and behavioral health care is at issue. They have the highest rates of avoidable deaths worldwide and are the most likely to skip care due to costs.

This blog has focused on varied population health and access to care challenges for racial and ethnic minorities, among other vulnerable and marginalized communities. Recent blogs addressed the dismal state of Maternal mortality and mental health, escalating women’s reproductive health crisis, and disappearing birthing centers across rural regions. The impact of systemic racism and other realities, such as trauma, on quality of care has also been of note. Considerable research identifies their influence on exacerbation and emergence of chronic physical and mental illness; every age group, gender, and individual across the cultural landscape is at risk. 

The 2020 International Health Policy Survey from the Commonwealth Fund and Organisation for Economic Co-operation and Development (OECD) highlights a plight worthy of notice: health care habits of American Men faced with financial insecurity. The report compares the access to, use, and affordability of care for males in the U.S. compared to 11 high-income countries. 

Startling Outcomes

The report summary focused on overall demographics by gender versus among racial and ethnic groups. The wholistic health triad of physical, behavioral, and psychosocial health gets primary attention yet again with troubling outcomes:

  • At least, 16 M men in the US lack health insurance:
    • Affordability of health plans remains the primary reason 
  • 45% of men have problems paying medical bills:
    • 67% of these men are frequently stressed about employment and/or financial security

Men in the U.S with income insecurity:

  • Are least likely to have a regular physician
    • They have the highest rates of Emergency Department use, especially for conditions that could have been treated in the Doctor’s office (e.g., asthma, diabetes, hypertension) 
  • Skip necessary care due to costs
  • Incur medical bills at the highest rates
  • Are least likely to access preventative care
  • Have the highest rates of avoidable deaths: 337/100,000
  • Are more likely to have integrated health issues, especially chronic conditions
    • Almost 30% have two or more chronic illnesses
    • Have significantly higher rates of smoking and alcohol use, and increased likelihood of having multiple chronic conditions:
      • 4X greater likelihood of being in fair or poor health
  • Have among the highest rates of mental health care needs: 35% of men

The Bottom Line and Mandate

At this point in time, the data affirms that rates of avoidable deaths, chronic conditions, and mental health needs for U.S. men remain the highest in the world; wholistic health equity quality is at a crossroads. Decreased access to routine preventative primary physical and behavioral health care is compromised by financial insecurity, as readily as traditional behavioral or cultural norms; this includes male resistance to appear vulnerable, weak, or infirmed. The cycle of reactive, emergent, and costly care has an identifiable cause that can be mitigated through a proactive means, encompassing:

  • Expanded access to affordable, comprehensive health coverage. 
  • Targeted person-centric and concordant care, including but not limited to:
    • increased access to racially, culturally, and ethnically-diverse providers and practitioners, as well as those trained in and sensitive to LGBTQIA wholistic health
    • Increased emphasis on integrated care frameworks that leverage patient engagement through comprehensive visits, concordant treatment approaches, and clinical expertise
      • Funding and reimbursement are also enhanced
    • Implicit bias training to debunk stigma and systemic racism, and also builds patient-provider trust
  • Collective efforts of providers, health plans, systems and organizations, and communities to promote preventive care and healthy behaviors, through targeted population-based engagement, psycho-education, and outreach

For my fellow wholistic health equity quality warriors, we’ve got miles to go before we sleep. Feel free to add further strategic recommendations and resources below.  

Trauma Amid Roe v. Wade Despair 

Amid my concern of the massive societal impact from overturning Roe v. Wade, lies the intersection of this decision’s havoc with every iteration of trauma.

Roe v. Wade has been overturned, and like many, I’m devastated. There will be mass impact of this decision across systems and sectors for generations to come. As I pondered a unique way to approach this blog post, one chronic theme came to mind. Amid my concern for all populations, lies the intersection of this decision’s havoc with every iteration of trauma.

Here are the facts: There is Pervasive Trauma

  • Vulnerable and marginalized populations live with rampant access to care obstacles; historical, experiential, and medical trauma are embedded within in the DNA of each person. 
  • The Turnaway Study released last Spring revealed stark facts of trauma’s wrath for women denied an abortion.
    • They are 4X as likely to end up living in poverty, stay with abusive partners, suffer from poor physical and mental health, plus have decreased aspirations. 
  • Collective Occupational Trauma for practitioners will further escalate as they reconcile:

There Will be More Trauma to Come

We can also expect:

  • Thousands of unplanned births and the potential for increased maternal morbidity and mortality; There will be trauma.
  • Increased mental health challenges for persons dealing with unwanted pregnancies; There will be trauma.
  • High rates of suicidal ideation, gestures, and action for victims of rape, sexual assault, and interpersonal violence who are forced to carry a pregnancy to full-term; There will be trauma.
  • A ripple effect for college-aged students facing an unwanted pregnancy, and forced to raise children on college campuses, delay, or give up hopes of earning a degree; There will be trauma.
  • Persons with chronic conditions, medical, psychiatric, and intellectual disabilities often face often life-threatening conditions when forced to maintain a pregnancy. “Abortion restrictions do not only endanger people who don’t wish to be pregnant. Many people who want biological children have conditions that put them at higher risk of adverse outcomes and miscarriages…this poses clear psychological risks, as well as physical ones”; There will be trauma
  • A rise in adverse childhood experiences scores for children born of unintended pregnancies, and for persons exposed to adverse life experiences; There will be trauma.
  • Threats to other rights and freedoms of ALL vulnerable and marginalized populations across the diversity, equity and cultural inclusion landscape; There will be trauma.

Moving Forward

Many associations and entities have already published position statements opposing the overturning of Roe V. Wade. This list of resources will fuel your advocacy energies:

ACLU

Center for Reproductive Rights

Center for Trauma-informed Policy and Practice

Guttmacher Institute

Human Rights Campaign

International Partners for Reproductive Justice (Ipas)

Keep Our Clinics

NARAL Pro-Choice America

National Abortion Federation

National Black Women’s Reproductive Agenda

National Latina Institute for Reproductive Justice

National Network of Abortion Funds

PACEs Connection

Planned Parenthood

Rape, Abuse, Incest National Network (RAINN)

Women Have Options

There are other countless other resources, and I invite all to add resources to this list. In the meantime, seek support by reaching out to each other: family, friends, colleagues, and counseling. Stay fierce, advocate, and ensure appropriate care for those in need. There will be ongoing emotions to reconcile as society contends with the new reality. We must be ready to ensure necessary health and mental health intervention, and for every person. After all, There will be trauma.

New Annual Report Highlights Economic, Educational, and Racial Disparities

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:

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.