Accelerating Health Equity in Government and the Private Sector

For nearly 20 years, value-based insurance design (VBID) has promoted the idea that patients should have easy access to affordable services that make individuals and populations healthy, explained A. Mark Fendrick, MD, director of the University of Michigan’s V-BID Center, during the 2023 virtual V-BID Summit. Fendrick is also the co–editor in chief of The American Journal of Managed Care^®.

This year’s V-BID Summit had the theme of “Accelerating Health Equity,” and it included a wide range of speakers, representing government, insurance, the pharmaceutical industry, academia, and patients.

“It makes perfect sense that we're landing here today on advancing health equity,” Clifford Goodman, PhD, senior vice president, The Lewin Group, said ahead of the first session. “The principles of health equity are in many ways embedded in the history and the mission of the V-BID Center.”

Goodman served as the moderator for all 4 panels during the 2023 meeting.

The first session of the day was the keynote, which included the following speakers:

• Grace Arnold, MPH, commissioner, Minnesota Department of Commerce, and cochair of the Special Committee on Race and Insurance at the National Association of Insurance Commissioners (NAIC)
• Joneigh Khaldun, MD, MPH, vice president and chief health equity officer, CVS Health
• Christen Linke Young, JD, deputy director, Domestic Policy Council for Health and Veterans

At the federal level, Linke Young has worked across the agencies to implement President Joe Biden’s priorities. She noted that the president had a deeply rooted commitment to driving equity from the first day in office when he signed an executive order directing agencies to use all policy levers to drive equity in all their decision-making.

Among the various problems she and the administration have tackled in the space of equity were:

• Insurance coverage and enrollment—Enrollment in Affordable Care Act (ACA) plans and Medicaid is at an all-time high. The uninsured rate is at 8%, which is the lowest point in history, Linke Young said. However, we’re entering a period of state Medicaid agencies making redeterminations for the first time since the pandemic started, and the administration is aiming to making that transition smooth as some people are undoubtedly rolled off Medicaid coverage. In addition, she highlighted 2 pieces of legislation—the American Rescue Plan and the Inflation Reduction Act—both of which dramatically lower health insurance premiums for people who don’t get coverage through work.
• Prescription drug costs—Medicare will now have the ability to negotiate drug prices for certain drugs and companies that increase drug prices faster than inflation will owe a rebate back to Medicare. In addition, Medicare beneficiaries will now have a $2000 cap on costs at the pharmacy and a $35 cap on a month’s supply of insulin. In addition, the president just unveiled a plan for $2 cost sharing for high-value generic drugs.¹
• Social determinants of health (SDOH)—Medicaid plays a critical role in this area, and the administration has been working on Medicaid waiver programs, demonstrations, and new investments that support SDOH by empowering states to coordinate with managed care organizations (MCOs) and embed investments into the drivers of health, such as housing, food stability, and safe transportation.

Moving down to the state level, Arnold explained that Minnesota put in place 6 priorities to make the state the best in the country for children to grow up and one priority is equity and inclusion.

The state has implemented an insulin affordability program, and the state’s Medicaid agency is looking at equity in its procurement process of selecting MCOs. In addition, the state has proposed studying how to have no-cost, no-barrier, free primary care. The goal is to take the tactics from COVID-19—when the state created locations for people to get tested or vaccinated even if they didn’t have insurance—and replicate them with basic care.

“It’s an equity proposal,” Arnold said. “It’s also one that can advance a lot of the goals of adding value and adding prevention into our system.”

At the NAIC, the special committee she cochairs is looking at measures to advance equity by lowering the cost of care and promoting access to care and health coverage.

“Engagement with communities is super, super important in any work you’re doing around equity,” she said.

There are a lot of assumptions that are made, but the communities can do a better job of explaining what they need. For instance, she related a story from the disability community, where the assumption was made that people with disabilities must be concerned about seeing specialists. However, the reality was that they know their specialists, but what they really needed is good primary care, which serves as the nexus of all of their care.

“Intentionally engaging [with the community] is really sort of critical to making sure that…we as regulators or policy makers are doing the right kind of work,” Arnold explained.

Since all states are different, NAIC’s goal by the end of the year is to create a toolbox for state regulators to go to and figure out a few different actions they can take to address the issues specific to their state.

While George Floyd’s murder in 2020 really galvanized the work around equity in Minnesota—the incident occurred a mile from Arnold’s house—CVS has been involved with health equity through Aetna’s work since 2002, when the health plan began collecting race and ethnicity data, explained Khaldun. At the time, collecting this sort of data was faced with a lot of pushback, but it meant being able to develop specific initiatives to address the disparities that were uncovered.

In 2021, CVS made the decision to create an executive position, which Khaldun was tapped to fill, to align health equity efforts across the entire organization. She pointed out that health equity cannot just be a series of programs focused on quick fixes because the disparities we see took centuries to develop.

CVS Health has 3 core pillars of its health equity work:

1. Empowering colleagues to know the strategy, understand why disparities exist, and provide tools to advance health equity in their daily work.
2. Utilizing data to understand where disparities are in order to address them, which requires standardizing and increasing the collection of self-reported health equity data.
3. Taking specific actions to address topic areas with a focus on the key drivers of health disparities in heart health, mental health, and women’s health.

Success in health equity is when we can measure health disparity gaps closing using live user data. As those gaps close, health outcomes for everybody should improve.

“Health equity is certainly not a zero-sum game,” Khaldun said. “It’s not a competition. It’s not about taking away from one group to give to another so that one group gets less health. It’s about raising all boats and making sure there are no gaps, and we get everyone what they really need.”

She concluded that health equity is not just a moral imperative—it’s a business imperative, too. In 2022, a Deloitte analysis found that annual health care spending related to health inequities could grow to $1 trillion or more by 2040.² The reason is because people have worse health outcomes, they use the emergency department more, have more chronic diseases, and are a greater burden on the health system.

“When you actually improve the health of people, you actually save the health care system money,” Khaldun said.

References

1. Fact sheet: the president’s budget: extending Medicare solvency by 25 years or more, strengthening Medicare, and lowering health care costs. White House. March 7, 2023. Accessed March 9, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2023/03/07/fact-sheet-the-presidents-budget-extending-medicare-solvency-by-25-years-or-more-strengthening-medicare-and-lowering-health-care-costs/

2. Deloitte analysis: health care costs for average American could triple by 2040 if health inequities are unaddressed while annual spending could exceed $1 trillion. Deloitte. News release. July 6, 2022. Accessed March 9, 2023. https://www2.deloitte.com/us/en/pages/about-deloitte/articles/press-releases/deloitte-analysis-health-care-costs-for-average-american-could-triple-by-2040-if-health-inequities-are-unaddressed-while-annual-spending-could-exceed-one-trillion.html