This is part two of our series on the Five Mechanisms of External Accountability for Health Equity. Read part one.
Most health systems today have started to engage in some form of health equity work, but few reckon with the role their institutions may have played in creating inequities in their communities in the first place. Being trustworthy and accountable for health equity solutions moving forward requires first being honest about and accountable for the past.
Historically, many healthcare delivery systems implemented and sometimes even profited from policies and practices that either ignored or actively drove health inequities, especially racial health inequities. This has taken many forms, such as outright denying access to care and work to people based on their race, gender, sexual orientation, ability, and country of origin. And harmful practices like this aren’t only a thing of the past. Recently, researchers found that by failing to prioritize equity in their design and implementation, value-based payment models often widened inequities in care. For example, all three of Medicare’s hospital value-based programs have transferred resources away from safety-net hospitals, and by doing so, penalized institutions that care for higher proportions of Black and Latino adults.
No set of institutional commitments to advancing health equity and racial justice can succeed without first initiating an honest accounting of its past and/or persistent practices that have caused long-standing harm to historically marginalized communities. And that honest accounting must be followed by making amends for those practices and taking steps to ensure they won’t happen again. This work of Redress and Restitution is the second of the Five Mechanisms of External Accountability for Health Equity (see image below) examined in this blog series.
What Redress and Restitution Looks Like in Practice
Few existing mechanisms or systems hold healthcare institutions accountable for acknowledging and making restitutions for past and present harms. However, there are examples healthcare institutions can look to for inspiration that build on models of redress and restorative justice in other fields.
Acknowledging systemic harm as the first step in a journey toward building community trust
Prior to 1963, Black patients were not routinely admitted to The Moses H. Cone Memorial Hospital in Greensboro, South Carolina, unless it was under the orders of a White physician. Health care, like much else in the city of Greensboro at the time, was deeply segregated until a lawsuit filed by six Black physicians, three Black dentists, and two Black patients went all the way to the Supreme Court to change that. Moses Cone Memorial Hospital quietly integrated, but for more than 50 years, that history went largely unacknowledged by the health system.
In 2010, staff surveys and community focus groups shone a light on just how deeply the health system’s history was still felt. Seeing the health system through its staff and community members’ eyes was the impetus for Cone Health to both formally begin health equity work and take accountability for its past. In 2016, the first step toward that accountability was to apologize publicly to the community and to Dr. Alvin Blount Jr., the last living plaintiff from the lawsuit. The second step was to listen more deeply to the communities most affected by that history and better incorporate community voice into the health system’s decision-making going forward.
Acknowledging and being accountable for its history is something Cone Health leaders continue to do in conversations with community organizations and members. While it’s an ongoing journey, Cone Health staff and community members in Greensboro have said that the acknowledgment of Cone’s history is a critical factor in beginning to build trust between the health system and the community as they work together to address ongoing health inequities both inside and outside clinic walls.
Applying a reparations framework to address specific health inequities
In 2019, after analyzing ten years of hospital data, physicians at Brigham and Women’s Hospital in Boston, Massachusetts, concluded that Black and Latinx patients with heart failure were more likely than White patients to end up on the general medicine service rather than on the cardiology service, where patients have better outcomes. Recognizing the role that structural racism played in the difference in care, Brigham and Women’s Hospital adapted economist William Darity Jr.’s acknowledgment, redress, and closure (ARC) reparations framework into a program called Healing ARC to address this inequity in care through three steps:
- Acknowledgement involves the recognition and admission of wrongs by perpetrators to beneficiaries of the injustice. In this instance, Brigham and Women’s is assembling focus groups from five neighborhoods with some of the highest populations of Black and Latinx residents to explain its heart failure findings, listen to responses and suggestions, and offer a space to discuss a just path forward. Additionally, the hospital is recruiting heart failure patients as co-collaborators in the Healing ARC initiative, while providers will acknowledge heart failure inequities at relevant points of entry into care.
- Redress means creating programs to monitor and end health inequities and offering restitution for past and present injustices. The hospital interpreted redress in this case as, “providing precisely what was denied for at least a decade: a preferential admission option for Black and Latinx heart failure patients to our specialty cardiology service.” Brigham and Women’s will include a flag in the electronic medical record and admissions system to suggest that providers admit Black and Latinx heart failure patients to cardiology, rather than relying on provider discretion or patient self-advocacy to determine where they receive care.
- Closure is about the community agreeing that the debt has been paid and creating a process for ensuring the same problem will not reemerge. Healing ARC will emphasize transparency through regular data, monitoring, and updates to the community on its progress, and hold conversations with community groups about debt repayment.
Charting a strategic health equity plan that centers redress and restorative justice
One of the five priorities of the American Medical Association’s (AMA) Strategic Plan to Embed Racial Justice and Advance Health Equity is to foster pathways for truth, racial healing, reconciliation and transformation for the AMA’s past. According to the plan, this includes: (1) amplifying and integrating often “invisible-ized” narratives of historically marginalized physicians and patients in all that AMA does; (2) quantifying the effects of AMA policy and process decisions that excluded, discriminated, and harmed; and (3) repairing and cultivating a healing journey for those harms. The AMA proposed over two dozen actions to work toward and hold itself accountable to this goal, including:
- Hosting restorative justice dialogues between AMA leadership and Black, Indigenous, Latinx, and other physicians of color and their communities and families;
- Launching, building, and tracking an AMA fellowship opportunity for AMA physicians in health equity and advocacy leadership;
- Hosting well-profiled conversations on AMA’s history;
- Developing and partnering on narrative projects that highlight experiences of physicians and communities most historically marginalized; and
- Conducting research to understand, confront, and dismantle dominant or malignant narratives (e.g., around race vs racism) that appear in medical journals and all across health care.
Questions You Should Ask About Your Healthcare Institution’s History and Actions
HealthBegins recommends finding opportunities to ask and discuss these five questions to support an honest unpacking and accounting of your healthcare institution’s past and/or present practices:
- In the last year, what steps has your institution made to assess how its own history helped drive and/or failed to prevent health inequities and racial injustice in the past?
- In the last year, what steps has your institution made to provide redress and make restitutions for its role in driving and/or failing to prevent health inequities and racial injustice (past and present)?
- Have institutional leaders publicly acknowledged, recognized, and admitted to wrongs by perpetrators to those who were harmed by the injustice?
- Have community residents and other constituents agreed that the institutional redress and restitution has been sufficient to correct for the health inequities and racial injustice it enabled or perpetuated?
- Have institutional leaders and staff implemented a continuous, ongoing process to identify, reform, and provide redress for existing practices that may be contributing to health inequities and racial injustice?
While these conversations can be held internally as part of C-suite, board, and staff meetings, it is critical that healthcare institutions involve, engage, and listen to patients and community members as part of this accounting. It is also common–as it was in the case of Cone Health–for staff and community members to be the ones asking these questions and driving the need for reckoning. Most importantly, to be both just and effective, policies and solutions that a healthcare institution enact to provide redress and restitution should be co-designed with and center the patients and community members most harmed by the original unjust policies.
By: Rishi Manchanda, Sadena Thevarajah, and Kate Marple