Moving the Needle on Health Outcomes: State Strategies for Advancing Health Equity

Stark health disparities make it difficult to move the needle on health outcomes and costs and reflect the fact that states face a variety of political and resource constraints when it comes to implementing health equity initiatives. Minority groups disproportionately bear the burden of disease. The CDC reports that when compared with white adults, African American adults are 40 percent more likely to have high blood pressure, have a 77 percent higher rate of diagnosed diabetes, and have a shorter life expectancy by nearly four years.[i] While these disparities still exist, all states have opportunities to advance health equity through a range of approaches, from incremental targeted programs to integration in broad health reform initiatives.

At NASHP’s 29th Annual State Health Policy Conference, held this past October, leaders from two states and the District of Columbia, all three of which have historically faced significant health disparities, shared their approaches to improving health equity by capitalizing on their unique strengths and resources. Louisiana, the District of Columbia, and Virginia have developed distinct strategies to fit their health care environments. These strategies range from expanding access to care for vulnerable populations, to weaving health equity components into broader state health care delivery system and quality improvement efforts, to launching discrete health equity initiatives that address the social determinants of health for all vulnerable populations.

Currently ranked 50th in the nation for overall health,[ii] Louisiana has mapped out a strategy to improve the health of all its residents that starts with increasing access to care. In June of 2016, Louisiana became one of a few southern states to expand Medicaid under the Affordable Care Act, raising Medicaid eligibility from 12 to 138 percent of the federal poverty level. With no funding allocated from its legislature to support the administrative costs of enrollment, Louisiana became the first state to use a State Plan Amendment to align Medicaid with Supplemental Nutrition Assistance Program (SNAP) enrollment. This enabled the state to defray the costs associated with a significant rise in the number of Medicaid applications and resulted in a streamlined application process for low-income residents. The state also expanded its outreach strategy to target vulnerable populations by adding Medicaid Application Centers to new locations, such as the offices of behavioral health providers. In just three months the state enrolled over 300,000 residents in Medicaid, of whom 50 percent are African American. Beyond Medicaid expansion, the state is also focusing on improving healthcare quality through a transparent quality measurement process that holds health plans accountable for improving health and disparities. For example, Medicaid managed care plans in Louisiana receive incentives for improving their performance on a quality measure related to avoiding pre-term births, an issue that disproportionately affects women of color.

District of Columbia
Despite having one of the highest health insurance rates in the nation, the District experiences many population health challenges, including significant disparities in health outcomes. In response to these challenges, D.C. has leveraged its State Innovation Model (SIM) Design Award to develop a State Health Innovation Plan that aims to reduce health disparities, improve health outcomes, and achieve health care savings for all residents. Strategies for improving health equity and addressing the social determinants of health are integrated within a variety of health care delivery system and payment reforms. For example, D.C. has proposed including homelessness as a qualifying condition for individuals to participate in a Health Home program that strives to better coordinate and integrate care for high-need Medicaid beneficiaries. The District has also proposed developing a more robust Health Information Exchange that would integrate health and social service data, such as housing, employment, and food security, to provide a more complete understanding of an individual’s wellbeing through a Patient Care Profile. To support such initiatives, D.C. is also considering an Accountable Health Community model to close gaps between clinical care and community services and leveraging non-clinical providers, such as community health works, who can reach at-risk populations.

While Virginia has not elected to expand Medicaid coverage, the state has leveraged the analytical capacity of the Department of Health to develop a targeted approach for identifying and addressing health disparities of all residents, regardless of insurance status. The Health Opportunity Index (HOI) is an innovative data analytics tool that enables the state to map social determinants of health at the community level. By measuring the medical, social, economic, educational, demographic, and environmental factors that influence the overall health of a community, the state is able to identify communities at high risk for poor health outcomes. The HOI distills this information into easily accessible dashboards and profiles that rate opportunities for healthy lifestyles at the census tract, county, health district, and legislative district level. Though the HOI only launched one year ago, several communities have already used it to identify opportunities and address barriers to healthy lifestyles. For example, community leaders in Stanton, Virginia discovered many of their residents were living in food deserts and were able to convene the appropriate multi-sector partners to re-map bus routes and enable access to healthy foods.

As we transition to a new administration, states and the federal government will continue to share a common interest in improving how health care is delivered and financed. From improving health care access and quality to developing partnerships beyond the traditional health care sector that support healthy lifestyles, these innovative strategies hold helpful lessons for states seeking to improve health outcomes for all populations in a rapidly changing health care environment.