August 2024 Health Equity News

Equity in Motion at CMS Health Equity: Aletha Maybank, MD, MPH, Shares AMA Advances for Justice

Chief Health Equity Officer and Senior Vice President Aletha Maybank, MD, MPH, of the American Medical Association (AMA) delivered a powerful plenary session on May 29, 2024, the first day of the CMS Health Equity Conference. She reflected on the journey toward equity, noting significant turning points that came in the aftermath of George Floyd’s murder and changes sparked by the spread of COVID-19.

Aletha Maybank, MD, MPH | Image credit: AMA

Maybank acknowledged the initiatives the AMA has implemented since then, centering the voices of the people who have been most marginalized in the country, specifically in the health care system. Then she emphasized that the work must go beyond acknowledgment to advance the state of health equity in the US.

“I’m very cautious in [making acknowledgments] at the same time because I don’t think we can be very flippant in just saying we’re [making] an acknowledgment; you need to be committed to the work as individuals and as institutions and have actions that actually demonstrate that,” Maybank said. “There are always a lot of conflicts to that in terms of institutional actions because sometimes the values…or the actions may not fully align, but it is critical…still to center the experiences of those who have been most marginalized.”

Before 2020, discussions of racism within institutions were often avoided, she explained. However, Floyd’s murder catalyzed a nationwide reckoning with racial injustice. For those engaged in equity work, Maybank recalled that this tragedy opened doors that had previously been shut. There was a pressing need to capitalize on the momentum and push for systemic change before the opportunity slipped away.

Referring to health equity work as a marathon, where efforts must endure while inequities exist, Maybank believes there are times to adapt the pace or to pass the baton to another when rest is needed.

“Sometimes we do need to sprint. We have to speed up because of the urgency of the moment,” she said. “And I know many of us have been sprinting over the last 4 years to get done what we needed to get done.”

Historically, the AMA has a complex relationship with racial justice,¹ having excluded Black physicians for over a century and remaining silent during key moments of desegregation, Maybank explained. However, in the wake of Floyd’s murder, the AMA made a bold move by acknowledging its past and committing to an explicit stance against racism.

Key policies emerged, such as renouncing racial essentialism and recognizing race as a social construct rather than a biological determinant.² According to Maybank, these policies have had a profound impact on medical education, research, and clinical practice, driving significant changes across the health care system.

Institutions such as the AMA have provided platforms for Black physicians and equity leaders, elevating their voices on national stages. Collaborations with leaders and publications from prestigious outlets have amplified the message of equity. Within the past 4 years, Maybank has contributed to a couple of articles published in JAMA and JAMA Network Open that focus on restructuring the US health care system after the COVID-19 pandemic³ and eliminating harmful race-based clinical algorithms.⁴

Internally, the AMA has made strides in embedding equity within its organization. Building a team dedicated to health equity and implementing strategic plans have been pivotal steps.⁵ These plans are aimed at establishing internal accountability, action on equity, and a comprehensive framework to track progress, contributing another rubric to those of other institutions that can be replicated.

“I also realized, being at AMA, the influence that it has had across the health ecosystem on the policies….” Maybank explained. “And thanks to the young physicians, the young folks, [and] the med[ical] students who put forward these policies to…really solidify [things],…I could—and anybody else who was doing work…and speaking on behalf of AMA could—explicitly talk about racism.”

The creation of tools and educational resources, such as the Health Equity Education Center, has equipped health systems and professionals with the knowledge to address inequities.⁶ Moreover, partnerships with organizations such as the CDC have facilitated the development of frameworks for equity in crisis preparedness and response.

Despite the progress, Maybank stated that the work has not been without resistance. Efforts to promote equity often encounter significant pushback, both from within institutions and from the public, with “dominant, malignant, and false narratives” that maintain the status quo. For instance, initiatives such as AMA’s Advancing Health Equity: A Guide to Language, Narrative and Concepts7 have faced criticism, with Maybank personally receiving threats, illuminating the contentious nature of equity work.

“Our opportunity at this given time, not only within health care but in our country, is a need for all of us to understand…those dominant narratives, malignant narratives, false narratives—whatever term you want to use—that are not working to advance equity within this country and within the systems that we have,” she said.

Focusing on the future of health equity in the US, Maybank concluded that the progress of the past few years demonstrates that when commitment, vision, and strategy align, significant change is possible. However, it also serves as a reminder that the fight for equity is ongoing, and the efforts to roll back progress are just as relentless. The urgency of the moment demands going beyond the metaphor of a marathon and acknowledging the need for sprints—times when rapid, decisive action is necessary.

References
1. Madara JL. Reckoning with medicine’s history of racism. AMA. February 17, 2021. Accessed June 4, 2024. https://www.ama-assn.org/about/leadership/reckoning-medicine-s-history-racism
2. Civil and human rights: elimination of race as a proxy for ancestry, genetics, and biology in medical education, research and clinical practice H-65.953. AMA. Updated 2020. Accessed June 4, 2024. https://policysearch.ama-assn.org/policyfinder/detail/racism%20social%20construct?uri=%2FAMADoc%2FHOD.xml-H-65.953.xml
3. Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 pandemic: the need for a structurally competent health care system. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289
4. Cleveland Manchanda EC, Aikens B, De Maio F, et al. Efforts in organized medicine to eliminate harmful race-based clinical algorithms. JAMA Netw Open. 2024;7(3):e241121. doi:10.1001/jamanetworkopen.2024.1121
The AMA’s 2024–2025 strategic plan to advance health equity. AMA. June 27, 2024. Accessed June 4, 2024. https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity
5. Health Equity Education Center. AMA Ed Hub. Accessed June 4, 2024. https://edhub.ama-assn.org/health-equity-ed-center
6. Advancing Health Equity: A Guide to Language, Narrative and Concepts. AMA Center for Health Equity. Accessed June 4, 2024. https://www.ama-assn.org/about/ama-center-health-equity/advancing-health-equity-guide-language-narrative-and-concepts-0

NASEM Report Reveals Persistent Challenges in US Health Equity

Recent evidence from a National Academies of Sciences, Engineering, and Medicine (NASEM) report has put persistent inequities in the US health care system into perspective. According to a news release from NASEM, despite the country’s position as a global leader in health care expenditure, the US has made minimal progress in advancing health care equity over the past 2 decades.¹ Racial and ethnic disparities are glaring defects in the nation’s health care system, leading to some of the poorest health outcomes among high-income countries.

Georges C. Benjamin, MD | Image credit: APHA

“Eliminating health care inequities is an achievable and feasible goal, and improving the health of individuals in the nation’s most disadvantaged communities improves the quality of care for everyone,” Georges C. Benjamin, MD, report committee cochair and executive director of the American Public Health Association, said in the release. “This is not a zero-sum game—we are all in this together.”

The report, “Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All,” is extensive, with a few key points regarding the ongoing and pervasive health care inequities.²

Persistent Racial and Ethnic Disparities
Various bodies have raised awareness and initiated action to address inequities in the country, yet significant disparities in health outcomes remain across racial and ethnic groups. Minority populations, particularly Black, Hispanic, American Indian, and those in Alaska Native communities, experience higher rates of chronic conditions such as diabetes and have poorer outcomes in areas such as maternal and infant health than their White counterparts. The report acknowledged that these disparities are rooted in longstanding structural inequities within the health care system and are exacerbated by social determinants of health (SDOH), such as socioeconomic status and access to quality care.

Diabetes is a poignant example of these inequities. The report states that American Indian and Alaska Native adults exhibit the highest prevalence of diabetes at 13.6%, followed by Black populations at 12.1%, Hispanic populations at 11.7%, Asian populations at 9.1%, and White populations at 6.9%. Despite these high rates, non-White patients often receive less access to newer, costlier medications and advanced diabetic technologies. Black patients with diabetes, for instance, have hospitalization rates more than 2.5 times higher than their White counterparts.

Structural Barriers in Health Care Access
The inequities are not confined to chronic diseases. A significant portion of the report delves into the structural inequities that pervade the health care system. Differences in services among public and private health insurance payers result in unequal access to care.

Report findings show that individuals from racial and ethnic minorities are significantly less likely to have a usual source of primary care. During emergency department visits, they endure longer wait times and receive less acute triage severity scores. Long-term care facilities that predominantly serve minority residents offer fewer clinical services, have lower staffing levels, and receive more care deficiency citations.

Incremental Progress and Ongoing Challenges
Over the past 20 years, progress has been made in raising awareness about health care inequities, conducting research, and implementing policies aimed at addressing these issues. However, there is no consistent evidence that equity gaps have been narrowing year after year for racial and ethnic minority groups.

The Affordable Care Act (ACA) played a significant role in expanding health care coverage and improving access to services across these groups. However, the report notes that structural limitations and legal challenges have impeded the realization of many of the ACA’s provisions.

Need for Comprehensive Policy Actions
To address these deep-rooted inequities, the report advocates for a range of actions at the federal, state, and local levels. Crucial recommendations include improving data collection on health disparities, increasing funding for programs that enhance access and quality of care for underserved populations, and enforcing existing laws designed to promote equity. The report also calls for substantial investments in research to better understand and develop interventions for health inequities, and it urges the alignment of Medicaid reimbursement rates with those of Medicare to ensure more equitable access to care.

Goals for Transformative Change
The report identifies 5 strategic goals with corresponding actions designed to foster comprehensive and systematic intervention at every level of health and health care:

• Generate accurate and timely data on inequities: Federal agencies should enhance the collection and use of data related to race, ethnicity, tribal affiliation, and language to better identify and address health inequities.
• Equip health care systems and expand effective interventions: Congress should increase funding for programs proved to have advanced access, quality, and equity in health care.
• Invest in research and evidence generation: The National Institutes of Health and other funders should expand their support for research focused on health care inequities, structural racism, and health-related social needs.
• Enforce existing laws and build accountability systems: Adequate resources must be allocated to enforce laws and regulations aimed at eliminating health care inequities.
• Eliminate inequities in coverage, access, and quality: Congress should establish pathways to ensure affordable, comprehensive health insurance for everyone and align Medicaid payment policies with those of Medicare.

“Many of the tools needed to reach these goals are already available and need to be fully used,” Jennifer DeVoe, MD, report committee cochair and professor and chair of the Department of Family Medicine at Oregon Health & Science University, said in the release. “And with concerted national effort and adequate resources, the health care system can be transformed to deliver high-quality, equitable care to all.”¹

References

1. Little progress has been made in closing racial and ethnic gaps in US health care; federal government should act to fix structural inequities. News release. NASEM. June 26, 2024. Accessed June 27, 2024. https://www.nationalacademies.org/news/2024/06/little-progress-has-been-made-in-closing-racial-and-ethnic-gaps-in-u-s-health-care-federal-government-should-act-to-fix-structural-inequities
2. National Academies of Sciences, Engineering, and Medicine. Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All. The National Academies Press; 2024. doi:10.17226/27820