VISIT STATE HEALTH COMPARE
Include Social and Economic Factors
Publication
“American Indian 101”: Understanding the history and contemporary experiences of Native people in a United States health policy context
American Indian and Alaska Native (AI/AN) is a racial/ethnic category that describes people with ancestry indigenous to North America prior to colonization in 1492. As of the 2020 U.S. Census, there were approximately 9.7 million Americans who identified as Native American alone or as Native American in combination with another race.
Despite millions of Americans identifying as AI/AN, Quin Mudry Nelson, MPH, SHADAC’s inaugural Health Equity Fellow, noticed a lack of attention on Indigenous and American Indian health and health care systems throughout their education. With their lens on health equity combined with their own experience as a Native person, they knew that Indigenous people in the U.S. face a number of health disparities compared to other groups, including, among others, the highest uninsured rate, lowest life expectancy at birth, and adverse impacts to health outcomes.
They also saw that it wasn’t only American Indian health services and systems being overlooked, it’s the people as well: data collection on AI/AN individuals is, and has been, a known challenge in the U.S. One report from the Department of Labor describes “substantial” criticism received “from tribes and other stakeholders regarding population undercounts, the accuracy and timeliness of the data, and the burden for tribes, due to lack of sufficient resources and trained personnel, in reporting the data to the Federal Government.”
After seeing these gaps between her education and her knowledge & experiences “as a two-spirit, Native person who is tribally affiliated with the Oneida Nation, I wanted to write a piece about AI/AN people’s history and identity in the context of health policy,” says Quin.
Quin’s in-depth research combined with their experience and understanding of the AI/AN community has culminated in this important brief: “American Indian 101”: Understanding the history and contemporary experiences of Native people in a United States health policy context.
Focused on health care and health insurance access among American Indian and Alaska Native people, this brief provides readers with essential context and commentary on United States and American Indian health policy, health disparities, and AI/AN identity as it relates to health care and policy.
The brief is divided into four sections, organized and grounded in the indigenous ways of knowing – outlining the present, reflecting upon the past, and using that context to chart a path for the future:
- Section 1 describes information about AI/AN people within the United States and the health care system presently, providing demographic data, a brief explanation on contemporary data collection issues, and a breakdown of the unique care delivery structure of the Indian Health Service
- Section 2 provides an overview of early U.S. history and American Indian health and social policies, including pivotal legal cases
- Section 3 contextualizes how this history constructed a unique identity for AI/AN people in comparison to other racial groups that impacts not only their access to care, but also to their “dedicated” health services
- Section 4 concludes with an overview of recent progress in AI/AN health and social policy, highlighting both potential future directions and limitations
This brief provides important historical context and actions that have shaped the landscape of American Indian health care today. Not only that, but this brief also provides a distinct perspective from an individual who has the lived experience of AI/AN people along with experience and education in public health and health equity.
Quin’s voice and ideas found in this brief are as intriguing as they are important. Publications with a foundation of personal perspective & experience such as this one are essential for uplifting voices from historically marginalized groups, identifying & spotlighting the structural issues that individuals face, and learning from the stakeholders who are impacted directly and indirectly.
Read the brief in full here or click on the image of the cover page above. We welcome any questions or comments – you can send them to Quin directly at nels9793@umn.edu.
Are you curious about American Indian health statistics, data collection, health care, health disparities, and more? You can start by delving into the references that informed this brief - these resources are rich with information. You can continue learning with some of the following SHADAC products and resources:
- Explore State Health Compare: Health Insurance Coverage by Race/Ethnicity (Includes AI/AN Breakdown)
- SHVS Brief: Collection of Race, Ethnicity, Language Data on Medicaid Applications: New and Updated Information on Medicaid Data Collection Practices in the States, Territories, and D.C.
- SHADAC Brief: The Kids Aren't Alright. Adverse Childhood Experiences and Implications for Health Equity
Blog & News
Research Assistant
What is Health Equity? — A SHADAC Basics Blog
October 28, 2024:
Basics Blog Introduction
SHADAC has created a series of “Basics Blogs” to familiarize readers with common terms, concepts, and topics that are frequently covered.
This Basics Blog will focus on the concept of health equity. We will answer and provide explanations for questions like:
- What is health equity?
- What is the definition of health equity?
- How can we talk about health equity in public health work?
- What are other supplemental terms and their definitions that are used in the health equity space?
With that foundation set, we then move into an example, using a study on provider discrimination data drawn from the Minnesota Health Access Survey (MNHA) to understand how to apply a health equity lens to public health work and analysis. Finally, we end with some further thoughts and considerations on our evolving understand of this complex concept.
Keep on reading below to learn more about health equity.
Health Equity Definitions
The Robert Wood Johnson Foundation, a philanthropic organization dedicated to advancing health equity and dismantling barriers in health care, defines health equity below:
It is important to note, though, that since health equity is conceptual, there is not a singular definition of it. This definition can also change and evolve, so it’s important to continue to educate yourself on health equity as time goes on.
What Is the Difference Between Equity and Equality?
While these two concepts are similar, equity and equality are not one in the same.
Equality is defined as giving the same treatment to everyone, regardless of individual needs or differences.
Equity is defined as giving treatment that is specific to individual needs, which allows everyone a fair chance at being successful.
The graphic below from the Robert Wood Johnson Foundation provides a visual representation of the difference between equality and equity. In the ‘Equality’ example, all people are given the same mode of transportation – they are given equal treatment. However, because the individual’s needs are not considered, the outcome is not necessarily equal as can be seen in the visual. In the ‘Equity’ example, each individual is given a mode of transportation that works for their needs, leading to a more equitable outcome as can be seen in the example.
Source: Joan Barlow, “We Used Your Insights to Update Our Graphic on Equity” Robert Wood Johnson Foundation, November 2022, We Used Your Insights to Update Our Graphic on Equity (rwjf.org). Reproduced with permission of the Robert Wood Johnson Foundation, Princeton, N.J.
Additional Terminology Definitions
The topic of health equity is complex, with many factors feeding into it. To further understand health equity, it is important to define these additional factors and terms as well. While this list is not exhaustive, the terms below all refer to larger barriers and systems that must be addressed in order to reach equity in health and health care.
Health Disparities: Avoidable differences in health outcomes experienced by people with one characteristic (race, gender, sexual orientation, etc.) as compared to the socially dominant group (e.g., white, male, cis-gender, heterosexual, etc.).
Measuring disparities can benchmark progress toward achieving health equity.
Social Determinants of Health (SDOH): The daily context in which people live, work, play, pray, and age that affect health. SDOH encompass multiple levels of experience from social risk factors (such as socioeconomic status, education, and employment) to structural and environmental factors (such as structural racism and poverty created by economic, political, and social policies).
These factors are known quantities that contribute to social and health inequities.
Social Inequities: Differences between groups that are unfair, unjust, systemic, and avoidable. Social inequities can be characterized by race, ethnicity, gender, age, sexual orientation, income, etc.
Social inequities can lead to poor health outcomes and further perpetuate systems and circumstances leading to health disparities (systemic racism, ableism, etc.).
Structural Racism: A complex system rooted in historical and current realities of differential access to power and opportunity for different racial groups. This system is embedded within and across laws, structures, and institutions in a society or organization. This includes laws, inherited disadvantages (e.g., the intergenerational impact of trauma) and advantages (e.g., intergenerational transfers of wealth), and standards and norms rooted in racism.
Structural racism contributes to a number of social determinants of health (SDOH). Public health systems must prioritize addressing structural racism as a primary barrier to health equity.
As you can see, many of these terms contribute to each other or are a result of another—truly showing how complex the topic of health equity is.
Using a Health Equity Lens on Provider Discrimination—Challenges and Interventions
Now that we have gone over some helpful terminology to keep in mind, let’s look at how to apply a health equity lens when looking at a real-life public health example.
The example we will go over in this section is related to LGBTQ+ health equity and discrimination. With roughly 13.9 million adults in the United States identifying as LGBTQ+, this example is both relevant and important for conversations on equity. Individuals of minoritized sexual orientation and gender identity have been historically marginalized, underrepresented in data, and faced with many health disparities, compared to their heterosexual, cisgender counterparts. These disparities exist for LGBTQ+ people not only at the national level, but also at the community, organizational, and smaller societal levels.
Thus, in June 2022, President Biden signed Executive Order 14075: Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals. This executive order is a sign of progress toward breaking down systemic barriers and more relatedly for this blog, empowering the Secretary of Health and Human Services (HHS) to “promote the adoption of promising policies and practices to support health equity” for this population.
Now we will look specifically at a relevant measure from the Minnesota Health Access Survey (MNHA) – provider discrimination by sexual orientation and gender identity (SOGI) in Minnesota – to demonstrate how we can perform studies, analyze results, and identify accessible solutions to health disparities by viewing them through a health equity lens.
The Data
Data coming from the 2021-2023 Minnesota Health Access Survey (MNHA) reveals that among all adults in Minnesota, over half of the transgender/non-binary population (56.3%) reported experiencing Sexual Orientation and/or Gender Identity (SOGI) based discrimination from health care providers – significantly higher compared with cisgender adults’ reported experiences of discrimination (6.7%).
Nearly 9 in 10 transgender/non-binary adults (88.1%) and about one in four (24.1%) cisgender adults who identified as gay/lesbian reported discrimination. Two thirds of transgender/non-binary adults (66.1%) and about a quarter of cisgender adults (23.9%) that chose the ‘none of these’ option for sexual orientation also reported discrimination. Discrimination among people who identify as bisexual/pansexual is also high, and not statistically different for transgender/non-binary adults (40.5%) and cisgender adults (31.6%).
Experiencing discrimination has been shown to negatively affect both mental and physical health, as individuals and members of historically marginalized communities report worse health status and may forgo or delay care to avoid further discrimination.
Now, let’s look at potential ways to equitably address instances of provider discrimination by sexual orientation and gender identity at various levels.
Community Level
There are various ways to approach the issue of addressing provider discrimination. One potential solution is to make changes to education for the overall medical community, such as implementing cultural competency and communication training.
Cultural competency describes services, practices, and processes that are responsive to diverse practices, assets, needs, beliefs, and languages for an array of individuals and communities. Examples of incorporating cultural competence in health care include:
- Promoting awareness and knowledge
- Recognizing one’s biases
- Engaging in cultural competence & bias training
- Using accessible language
- Familiarizing oneself with the local community
- Recruiting diverse team members
Embracing these strategies can help immensely in understanding and reducing stigma as well as strengthening relationships between providers and the unique communities they serve.
Incorporating cultural competence into care can therefore offer meaningful ways to make strides toward reducing reported discrimination rates, such as those from individuals reporting SOGI-based provider discrimination in Minnesota. When cultural competence is practiced, better and more equitable health outcomes are observed for patients. Improved trust and communication between providers and patients can lead to more regular interactions with the health care system (like routine preventative visits), which can in turn lead to better treatments, health outcomes, and even better overall health status, another known issue for LGBTQ+ individuals.
Organizational Level
Addressing provider discrimination at a higher organizational level can be done through changing health systems and how they operate. Structural issues, such as payment/reimbursement structures, lack of time for visits, and workforce diversity may also contribute to the discrimination felt by different individuals.
Structural competency, which is the belief that inequalities in health must be conceptualized in relation to the institutions and social conditions that determine health related resources, can then play a crucial role in promoting equitable care alongside cultural competency by addressing issues at a structural level. This concept can be implemented in health systems through training in five core competencies:
- Recognizing the structures that shape clinical interactions
- Developing an extra-clinical language of structure
- Rearticulating “cultural” formations in structural terms
- Observing and imagining structural interventions
- Developing structural humility
Structural training and education helps medical professionals more effectively understand the economic and social determinants of health (SDOH) that occur for their patients before any interaction with the health care system occurs. In the instance of individuals belonging to the LGBTQ+ community, these can take the shape of lack of health insurance coverage or access barriers. Additionally, organizations can invest in structural changes to advance health equity through improved data systems that are able to track populations’ diverse makeup (race, ethnicity, sexual orientation, gender identity, primary language), alongside SDOH (income, education, employment) and health needs (utilization of care, treatment, and health outcomes), to better understand who they are serving and how to improve services.
Societal Level
On a larger scale, the state of Minnesota has made it a goal to ensure all Minnesotans receive high quality health care, free of provider or system bias.
Citing the 2021 Minnesota Health Access Survey (MNHA) data on responses to unfair treatment, the Minnesota Department of Health (DHS) recognized the disparity between the higher rates of unfair treatment by Black Minnesotans (39%) and Transgender Minnesotans (50%) compared to White Minnesotans and cis-gendered men (9% and 12%, respectively), and created a measurable goal to directly address this issue.
By 2027, MN DHS states that it hopes to reduce the percentage of transgender and non-binary Minnesotans and Black Minnesotans reporting unfair treatment by their providers by 50%. This goal is a meaningful step toward health equity for individuals with different racial and ethnic backgrounds and different gender identities.
Shifting Definitions and Future Considerations
In the example above, examining reported rates of provider discrimination in Minnesota and potential solutions at different levels helps to understand not only a practical example of how better understanding of health equity and systemic issues can clarify what the major barriers to advancing equity look like, but also how they can be addressed.
Even now as the definition of health equity is not set in stone and continues to evolve, we see opportunity for solutions to advance health equity--both in general, and for people with minoritized sexual and gender identities--to evolve as well. However, this does not apply only to health equity, as the definitions and understanding of many of the terms described above have evolved over time. As society and demographics continue to shift, so does our insight and understanding of these concepts.
There is a need for more involvement at the community, organizational, and societal level in advancing health equity. While there is progress in the right direction, there are still structural barriers that need to be overcome and met with applicable solutions that lead to positive systemic change.
Interested in learning more about health equity? Now that you have the SHADAC Basics down, try some of the following resources to continue to expand your knowledge:
Publication
Impact on Vital Community Conditions: Underlying Factors of Medicaid Inequities Annotated Bibliography
*Click here to jump to the 'Impact on Vital Community Conditions' annotated bibliography*
The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care
- Impact on Vital Community Conditions
This page is dedicated to a single section from the full annotated bibliography:
Impact on Vital Community Conditions
Underlying Factors Annotated Bibliography: Impact on Vital Community Conditions
Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.
Click on the arrows to expand / collapse each source.
Semprini, J., Ali, A. K., & Benavidez, G. A. (2023). Medicaid Expansion Lowered Uninsurance Rates Among Nonelderly Adults In The Most Heavily Redlined Areas. Health Affairs, 42(10), 1439–1447. https://doi.org/10.1377/hlthaff.2023.00400
Author(s): Jason Semprini, University of Iowa, College of Public Health; Abinasir K. Ali, University of Iowa, College of Public Health; and Gabriel A. Benavidez, Department of Epidemiology and Biostatistics, University of South Carolina
Article Type: Peer-reviewed journal
While there has been ample research on the effect of Medicaid expansion on reducing individual-level racial and ethnic disparities in health insurance coverage, authors here attempt to fill the gap in research on how Medicaid expansion is affected by root causes of health inequities, such structural racism, as measured by the historically racist policy of residential redlining. The federal government’s rating system for mortgage investments, which benefited white, upper middle-class families and penalized minoritized communities and the working-class, has had lasting effects even after it was outlawed in the late 1960s. These effects include substantial wealth gaps, under-resourced communities, and poorer health outcomes. The authors use data from national surveys and a difference-in-differences design to explore how exposure to historical redlining may have influenced the effect of Medicaid expansion on population-level insurance rates for non-Hispanic Black, non-Hispanic White, and Hispanic nonelderly adults. When comparing uninsurance rates in Medicaid expansion and non-expansion states before and after the passage of the Affordable Care Act, authors found that Medicaid expansion had the greatest impact on lowering uninsurance rates in areas with the highest level of historic redlining. Even though no statistically significant differences were observed by race and ethnicity within each redline category, authors conclude that “Medicaid expansion may have helped to reduce some of the negative consequences of structural racism…” and emphasize the importance of studying contextual factors when evaluating health programs and policies.
Londhe, S., Ritter, G., & Schlesinger, M. (2019). Medicaid Expansion in Social Context: Examining Relationships Between Medicaid Enrollment and County-Level Food Insecurity. Journal of Health Care for the Poor and Underserved, 30(2), 532–546. https://doi.org/10.1353/hpu.2019.0033
Author(s): Shilpa Londhe, Department of Health Policy and Management, Yale School of Public Health; Grant Ritter, Heller School for Social Policy and Management, Brandeis University, Mark Schlesinger, Department of Health Policy and Management, Yale School of Public Health
Article Type: Peer-reviewed journal
This article studies the relationship between county Medicaid enrollment and food insecurity in over 350 counties. The authors acknowledge that food insecurity prevalence ranges widely across the country, from as low as 4 percent up to 39 percent in some states. The authors observe that counties who expanded their Medicaid program in 2012 had significantly reduced food insecurity compared to their baseline year of 2009, and compared to counties that expanded later in calendar year 2014. While the authors acknowledge that food insecurity and lack of insurance coverage are likely related, they conclude that Medicaid likely offers greater financial security overall, which alludes to many improvements for low-income families, with overcoming food insecurity being one positive of many likely effects.
Bowen, S., Elliott, S., & Hardison-Moody, A. (2021). The structural roots of food insecurity: How racism is a fundamental cause of food insecurity. Sociology Compass, 15(7). https://doi.org/10.1111/soc4.12846
Author(s): Sarah Bowen, Professor of Sociology at North Carolina State University; Sinikka Elliot, Associate Professor of Sociology at the University of British Columbia; Annie Hardison-Moody, Associate Professor of Agricultural and Human Sciences at North Carolina State University
Article Type: Peer-reviewed journal
This article, written by scholars in the US and Canada and funded by the US Department of Agriculture, provides a detailed overview of the patterns of food insecurity in the recent past. These patterns of food insecurity include that it is associated with lower income households, mostly cyclical as opposed to chronic, more prevalent in households with children and in households headed by women, and households headed by people of color and people with disabilities. Food insecurity also has negative effects on physical and mental health as well as academic performance and risk of hospitalization among children. Authors summarize evidence on the association between food insecurity and poverty, other forms of hardship, housing insecurity, and neighborhood support systems, but argue that there is a more fundamental cause for food insecurity: racism and persistent unequal access for people of color to opportunities and resources. To combat food insecurity, structural change is needed. While the article does not go into detail about specific recommendations for the Medicaid program, it references advocating for Medicaid expansion and against “...punitive and stringent policies that disproportionately harm people of color…,” which can be the price for access to assistance.
Charania, S. (2021). How Medicaid and States Could Better Meet Health Needs of Persons Experiencing Homelessness. AMA Journal of Ethics, 23(11), E875-880. https://doi.org/10.1001/amajethics.2021.875
Author(s): Sana Charania, George Washington University’s School of Public Health in Washington, DC
Article Type: Peer-reviewed policy reform brief
This peer-reviewed policy reform brief includes a list of strategies that state Medicaid programs can pursue with providers to alleviate health care stressors of those experiencing homelessness. The author remarks that in 2020, over half a million people experience homelessness on any given night in the United States. According to survey data from a decade earlier, about a quarter of “…sheltered persons experiencing homelessness had a severe mental illness and 35 percent had problems with substance use”. The author states that there is a need for better supportive housing options and discusses studies in several states that showed providing permanent housing and needed services (such as behavioral health care) to individuals who were previously homeless led to decreased inpatient or emergency department visits and lower health care costs. The author emphasizes that it is not entirely on state Medicaid programs to reach those experiencing homelessness; clinicians and hospitals have a role to play in resolving biases about this very stigmatized group of people and assessing the basic needs of their patients. The author does highlight the importance of Medicaid expansion under the ACA – citing the improved health conditions of those experiencing homelessness and an increase in coverage in expansion states.
Dennett, J. M., & Baicker, K. (2022). Medicaid, Health, and the Moderating Role of Neighborhood Characteristics. Journal of Urban Health, 99(1), 116–133. https://doi.org/10.1007/s11524-021-005792
Author(s): Julia M. Dennett, Yale University School of Public Health, New Haven, CT; Katherine Baicker, University of Chicago Harris School of Public Policy, Chicago, IL and the National Bureau of Economic Research, Cambridge, MA.
Article Type: Peer-reviewed journal
This article is an analysis of whether key neighborhood characteristics, such as “socioeconomic deprivation (which is a score that reflects neighborhood ethnicity, education, employment, poverty, and housing/crowding), food access, park access and green space, attributes that promote active living, and land use” influence the effect of health insurance coverage on health outcomes. Using data collected in 2009 and 2010 about participants in the Oregon Health Insurance living in the Portland area, some of whom had access to Medicaid coverage and some of whom did not, authors found neighborhood characteristics played only a limited role in moderating the impacts of coverage on select health outcomes. The study’s null findings imply that Medicaid expansion benefited many across the board, regardless of neighborhood. Also implied is that the relationship between coverage and neighborhood characteristics and health outcomes is complex. Authors note several study limitations, including other factors to consider in the definition of neighborhood characteristics and their inability to conduct subgroup analyses. They also call for future research to inform policy.
Satcher, L. A. (2022). (Un) Just Deserts: Examining Resource Deserts and the Continued Significance of Racism on Health in the Urban South. Sociology of Race and Ethnicity, 8(4), 483–502. https://doi.org/10.1177/23326492221112424
Author(s): Lacee Satcher, Professor of Sociology and Environmental Studies at Boston College
Article Type: Peer-reviewed journal
This peer-reviewed article summarizes research examining the relationship between resource scarcity (measured in terms of multiply-deserted areas (MDAs)) and health. The author goes on to discuss how this relationship varies according to race and class composition of urban neighborhoods in the South and its implications for public programs, including Medicaid. MDAs were constructed based on three types of resource deserts: food, green spaces, and pharmacy deserts. Health outcomes examined included adults with diabetes, obesity, asthma, and no leisure-time physical activity. Results show that, compared to less resource-scarce areas, MDAs are associated with higher disease prevalence as well as higher rates of inactivity. Co-occurring resource scarcity has more influence on outcomes and activity levels than single-resource scarcity resulting in greater stress and negative impacts on health. “While there have been efforts to increase food access or greenspace for low-income, predominantly Black neighborhoods via farmer’s markets and community gardens, understanding that these neighborhoods are experiencing compounded, co-occurring resource scarcity calls for a more comprehensive policy intervention or community initiative that increases access to healthy foods, greenspace, and prescription medicines.” The author explains further that, “reducing disparities in prescription access and adherence via expansion of Medicare Part D and Medicaid are important, but study findings suggest that policy efforts to reduce disparities should also increase spatial access to pharmacies.”
Wei, Y., Qiu, X., Sabath, M. B., Yazdi, M. D., Yin, K., Li, L., Peralta, A. A., Wang, C., Koutrakis, P., Zanobetti, A., Dominici, F., & Schwartz, J. D. (2022). Air Pollutants and Asthma Hospitalization in the Medicaid Population. American Journal of Respiratory and Critical Care Medicine, 205(9). https://doi.org/10.1164/rccm.202107-1596oc
Author(s): Yaguang Wei, Xinye Qiu, Mahdieh Danesh Yazdi, Longxiang Li, Adjani A. Peralta, Cuicui Wang, Petros Koutrakis, Antonella Zanobetti, are all from the Department of Environmental Health at Harvard T.H. Chan School of Public Health; Matthew Benjamin Sabath Francesca Dominici are from the Department of Biostatistics at Harvard T.H. Chan School of Public Health; Kanhua Yin is from the Department of Epidemiology at Harvard T.H. Chan School of Public Health; and Joel D. Schwartz is associated with both the Department of Environmental Health at Harvard T.H. Chan School of Public Health as well as the Department of Surgery, Massachusetts General Hospital, Harvard Medical School.
Article Type: Peer-reviewed journal
This peer reviewed study analyzes inpatient claims of Medicaid beneficiaries from 2000 to 2012 by zip code in order to determine the effect of three common air pollutants (nitrogen dioxide, ozone pollution, and particulate matter) on asthma hospitalizations. The researchers found a positive relationship between short-term exposures and increased risk of asthma hospitalization for those with one asthma admission during the study period, but air pollutants appeared to be less of a factor for those with multiple asthma admissions during the study period. A community-level analysis found higher risk of asthma hospitalization for people living in low population density zip codes, people with higher average BMI, and people living a longer distance to the nearest hospital. There were no significant differences in risk of asthma hospitalizations by race or ethnicity. These results emphasize the importance of both individual and contextual factors in assessing the quality of health care for the Medicaid population, where the impact of air pollutant exposures on asthma susceptibility differed by severity and place characteristics.
[1] State Health & Value Strategies (SHVS). (2021). Talking about anti-racism and health equity: Discussing racism. https://www.shvs.org/wp-content/uploads/2021/08/Talking-About-Anti-Racism-Health-Equity-1-of-3.pdf
Blog & News
Research Assistant
Integrated Health Partnerships—Minnesota’s Medicaid Accountable Care Organization Model
August 16, 2024:Minnesota's Integrated Health Partnerships (IHPs) have pioneered a new approach to implementing accountable care organizations (ACOs) for the Medicaid population. Initially launched in 2013 by the Minnesota Department of Human Services (DHS), these partnerships are voluntary agreements between health provider groups and DHS. Health provider groups partner directly with DHS in multi-year contracts to both improve the quality of and reduce the total cost of care for specified patient populations using a shared savings/shared risk financing model.
When IHPs were first established in Minnesota, there were six provider groups participating. A little more than 10 years later, the number of IHPs in Minnesota has more than tripled, with 25 total partnerships covering more than 505,000 beneficiaries, as of July 2024.
DHS released the 2025 Request for Proposals (RFPs) (which recently closed) hoping to expand the program to more interested organizations and to allow current organizations to continue their partnership with the agency.
In order to better understand potential expansions and changes that may be implemented through Minnesota’s IHPs, we must first understand the foundation, function, and purpose of these partnerships.
In this blog, SHADAC staff will explore:
- What is the purpose of an Accountable Care Organization (ACO)?
- How do IHPs relate to ACOs?
- How have IHPs been established in Minnesota and how have they evolved?
- How can IHPs advance health equity for included populations?
- What are some future considerations that could help in better understanding the effect of IHPs?
Keep reading to start learning about the IHP program and how it impacts communities in Minnesota.
ACOs in Medicaid
Accountable Care Organizations (ACOs) are groups of health care providers that agree to take financial responsibility for the quality and cost of care they deliver to a defined patient population. There are national, state, and regional ACO models, and they may support multiple insured populations, i.e., Medicare, Medicaid, commercial, and self-insured.
ACOs often operate alongside Managed Care Organizations (MCOs), offering additional avenues for health care reform and focusing increasingly on advancing health equity. ACOs are a pivotal tool in promoting access to care, investing in population health, and addressing social determinants of health that affect health equity.
Since the enactment of the Affordable Care Act (ACA) in 2010, the Center for Medicare and Medicaid Innovation (CMMI) has supported state initiatives like Minnesota's State Innovation Model (SIM) to test and expand ACO models within Medicaid, and Medicaid-specific ACOs have now been established in nearly a dozen states.*
These programs vary by state in terms of delivery system reform, payment expectations, and in the authorities needed to administer them, but all such Medicaid ACO alternative payment models (APMs) are standardized through classification under Categories 2, 3, and 4 of the Health Care Payment – Learning Access Network (HCP-LAN) APM framework.
IHPs are Minnesota’s Medicaid ACO model. In 2008, the Health Reform Law of Minnesota included recommendations for statewide quality reporting, payments for coordinated care services provided in health care homes (HCHs), and encouragement to participate in bundled payment demonstrations. The law was then amended in 2011 to require DHS to develop a program to “test alternative and innovative health care delivery systems, including ACOs that provide services to a specified patient population for an agreed-upon total cost of care or risk/gain sharing payment arrangement”, leading to the creation of IHPs.
In 2017, SHADAC had the opportunity to conduct an evaluation of early Minnesota IHP implementation as part of Minnesota’s SIM cooperative agreement with CMMI, which documented IHP expansion and evolution, helpful data analytics, and importance of ongoing monitoring of the effects of the IHP program on health care utilization, cost, and quality.
Minnesota's Integrated Health Partnerships Today
As noted earlier, Minnesota’s IHP program began over 10 years ago in 2013. In 2018, the program was updated with various enhancements and changes in order to place a stronger focus and effort on health equity, enhance the risk arrangement incentives, and provide a population-based payment. This led to the implementation of a new overall IHP model (Integrated Health Partnerships 2.0) with two possible tracks for Minnesota IHPs to operate under (see figure below). These two distinct organizational design tracks are tailored to both provider capabilities and population needs.
For full details and requirement on IHP design tracks, please reference the Minnesota Department of Human Services 2025 Request for Proposals for IHP Program
On top of improving care quality and reducing the total cost of care, IHPs on both tracks are also required to design interventions that address specific health disparities across their target population. IHPs in both tracks receive a quarterly risk-adjusted population-based payment (PBP) which is intended to contribute to care coordination and other investments for the population served. IHPs are also assessed based on quality, utilization, and health equity measures. This population-based payment is flexible, adjusting to reflect changing numbers of the included population specified by the IHP’s intervention plan, as well as changing risk factors due to medical and social complexities in the population makeup.**
IHPs are measured through quality and data metrics (e.g., comparing percent change between performance years), as well as a calculation of standards across five domains for those in the shared-risk model - Quality Core Set, Care for Children and Adolescents, Quality Improvement, Closing Gaps, and Equitable Care - a process which is described in further detail in the following section.
Ultimately, IHPs have proven quite successful in Minnesota, with significant savings and quality improvements. Since their inception, IHPs have yielded nearly $546 million in total savings through 2022.
Emphasis on Advancing Health Equity
In response to evolving health care needs and feedback suggesting that the timing was right to build on prior successes of the original IHP program, DHS introduced an improved program, IHP 2.0, enhancing its focus on health equity. The IHP 2.0 program, included modifications to allow the program to more directly address social determinants of health (SDOH) and incentivize partners to reduce racial, geographical, and/or other disparities.
The Minnesota Department of Health describes health equity as “addressing health disparities as part of a broad spectrum of public investments in housing, transportation, education, economic opportunity and criminal justice.” By implementing changes and integrating health equity goals into core operational frameworks, the hope with the IHP 2.0 program is to overcome the limitations of traditional health care approaches in addressing SDOH and health disparities that arise as a result.
In fact, recent case studies on Medicaid payment reforms conducted by the Urban Institute directly referenced and cited Minnesota’s IHPs, describing their influence on health equity along with the overall changes made to the program in 2018 in order to continue to advance equity in Medicaid.
The table below from the Urban Institute identifies and describes the core features of the IHP 2.0 program designed to both focus on and advance equity for beneficiaries.
Source: Allen & Willis, “Can Medicaid Payment and Purchasing Strategies Advance Health Equity?” The Urban Institute, December 2023, https://www.urban.org/sites/default/files/2023-12/Can%20Medicaid%20Payment%20and%20Purchasing%20Strategies%20Advance%20Health%20Equity_0.pdf
As described above, the success of IHPs is evaluated based on performance in health care quality, utilization, health equity, and total cost of care (TCOC). When monitoring quality for those in risk arrangements where quality has an impact on shared savings and losses, the quality-related assessments are organized into five domains.
As a reminder, those domains are as follows:
- Quality Core Set
- Care for Children and Adolescents
- Quality Improvement
- Closing Gaps
- Equitable Care
Two of these domains, “Closing Gaps” and “Equitable Care,” specifically target health equity through tailored clinical and utilization measures aimed at reducing and eliminating disparities among specific Medicaid populations. IHPs can also receive ‘bonus points’ on their overall quality score for creating additional initiatives under the Quality Improvement, Closing Gaps, and Equitable Care domains.
Recent Health Equity Interventions
As a part of the enhanced focus on health equity, IHPs are encouraged to design interventions to address targeted populations’ health equity challenges.
Target populations may differ among the IHPs, with some initiatives aimed at supporting the entire IHP patient population and some designed to serve a more specific sub-population. A summary list of common target populations of Minnesota’s 25 IHPs include:
- Children, adolescents, families, and new mothers
- Justice-involved individuals
- Patients with a mental illness or individuals living with a family member with a mental illness
- Patients that are food insecure
- Adults with substance use disorder
- Individuals experiencing challenges accessing care, including Black, Indigenous, and people of color
A summary list of common social risk factors across Minnesota’s 25 IHPs include:
- Housing instability
- Food insecurity
- Social isolation
- Transportation
- Difficulty paying bills
- Education
- Employment
- Mental health needs
- Access to care
- Language barriers
- Income
- Childcare
IHPs must first identify the population or populations that they are serving, and then they must design, develop, and implement targeted intervention efforts based on those populations, risk factors, and SDOH to advance equity for those groups. IHPs are encouraged to identify an intervention that will meet the needs of their specific population given their knowledge of their community. Examples of these efforts include community partnerships, screening initiatives, referrals to community resources or other needed programs, and care coordination for social needs. The following is a summary list of common interventions currently being used to address health equity across Minnesota’s 25 IHPs:
For a full list, the Health Equity Interventions Summary at this link provides the specific target population, social risk factors, interventions, and milestone components for each IHP in Minnesota.
Closing Thoughts
As DHS’ IHP Program continues to evolve, its focus on data analytics and population health management remains pivotal for achieving comprehensive care delivery and advancing health equity statewide. The IHP 2.0 Program exhibits the importance of translating equity-focused policy goals into actionable requirements and programs. DHS’ work to monitor and disseminate the outcomes of the health equity initiatives and interventions implemented by IHPs will continue to provide valuable insights into their effectiveness and impact on Minnesota's health care landscape.
One potential dissemination method would be to make the Population Health Reports from IHPs publicly available. This would not only increase transparency around the data collected by IHPs and the lessons learned from putting interventions into practice, but also aid in our understanding of the effectiveness of IHPs in addressing SDOH, improving access to care, and eliminating health disparities.
Continue learning about health equity in Medicaid and beyond with the following SHADAC products:
Notes
Publication
Reproductive Oppression in Health Care: Underlying Factors of Medicaid Inequities Annotated Bibliography
*Click here to jump to the 'Reproductive Oppression in Health Care' annotated bibliography*
The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care
- Impact on Vital Community Conditions
This page is dedicated to a single section from the full annotated bibliography:
Reproductive Oppression in Health Care
Underlying Factors Annotated Bibliography: Reproductive Oppression in Health Care
Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.
Click on the arrows to expand / collapse each source.
Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health (2002), 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882
Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine
Article Type: Peer-reviewed Journal
The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).
Morcelle, M.T. (2022). Reforming Medicaid Coverage Toward Reproductive Justice. American Journal of Law & Medicine, 48, 223–243. https://doi.org/10.1017/amj.2022.27
Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office
Article Type: Peer-reviewed journal
The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.
Thompson, T. M., Young, Y.-Y., Bass, T. M., Baker, S., Njoku, O., Norwood, J., & Simpson, M. (2022). Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs, 41(2), 195–202. https://doi.org/10.1377/hlthaff.2021.01422
Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective
Article Type: Peer-reviewed journal
This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.
Ogunwole, S. M., Karbeah, J., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health Equity Considerations in State Bills Related to Doula Care (2015-2020). Women's Health Issues: Official publication of the Jacobs Institute of Women's Health, 32(5), 440–449. https://doi.org/10.1016/j.whi.2022.04.004
Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health
Article type: Peer-reviewed journal
This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process.
[1] Women's Leadership and Resource Center. (2023). Reproductive Oppression Against Black Women | Women’s Leadership and Resource Center | University of Illinois Chicago. Wlrc.uic.edu; University of Illinois Chicago. https://wlrc.uic.edu/reproductive-oppression-against-black-women/
