Health inequities in aging, part two

In part one of my blog series, I detailed some of the health care inequities faced by aging Americans of color in an interview that was part of the AARP Illinois Disrupt Disparities Summit. In part two, I want to address another question posed:

 “Responses to the chronic diseases that older adults of color suffer disproportionately are focused on changing individual behavior. Research suggests though that this chronic disease prevalence can be the result of systematic inequalities. What systemic policy changes could address these chronic health inequities for older adults of color?”

So much of an individual’s health is determined by where you live; a huge systemic factor that affects access to employment, education, transportation, broadband access and other opportunities. Federal policies that controlled access to mortgage loans, a practice known as “redlining,” were used to restrict African Americans to certain neighborhoods.

Although the policy started in the 1940s, through the under resourcing of these neighborhoods and denial of opportunity, we still experience the effects today. Even health “choices” like what to eat can be related to neighborhood-based lack of access to healthy produce. Smoking, food and alcohol abuse can be due to self-medication for untreated trauma for those without access to mental health services. Therefore, approaches and policies must be wide ranging and address the damage from decades of systemic racism and inequality. Some starting points for a new system-based approaches include:

1. Use quality measures as indicators of closing health disparity gaps for communities of color. These measures, which are being developed by various organizations including the National Committee for Quality Assurance (NCQA), can form the basis for provider accountability and value-based payment incentives for those who demonstrate success.
2. Use data analytics to understand the interplay between clinical and social risk and delineate which patients and communities are at higher risk for poor health outcomes. Having an integrated view of clinical and social risk allows for targeted interventions for more complex individuals. It also allows providers who successfully close gaps in care for patients with higher socio-medical risk to be appropriately compensated since more staff and technology resources are often required to do so. Providers will therefore not avoid the investments needed to be successful in managing more complex patients.
3. Facilitate access to care for older adults. In one practice I worked in we established a telehealth hub where, during one primary care office visit, you could also virtually see a case manager, cardiologist, pharmacist or psychiatrist. This greatly benefitted older adults with mobility or transportation issues. The next step is in-home telehealth services, now commonplace due to pandemic-induced changes in reimbursement. But seniors of color disproportionately face a digital divide, affordable broadband, easy to use devices and training in how to use them.
4. Develop a culturally component workforce. Existing providers who may not be aware of the bias they bring to interactions with patients of a different color, sexual orientation or generation than they are, may negatively influence health outcomes. Health care organizational culture that reflects a commitment to cultural competency, and the necessary staff training to support it, is a start toward addressing implicit bias. An important corollary is the hiring staff who reflect the diversity of the patients being served by the institution, as well as developing care navigators from the communities being served to assist older adults in coordinating their care and improving their health literacy and self-care skills.

Health care disparity is not solely an individual problem; it is a community and system problem. As a society, we must ensure we reach health equity for the most vulnerable within the health care system.

Melissa E. Clarke, MD, CMQ, is senior medical director, health care transformation and health equity, at 3M Health Information Systems.

References

1. Disrupt Disparities: Challenges and Solutions for 50+ Illinoisans of Color. AARP Illinois, Asian Americans Advancing Justice Chicago, Chicago Urban League, The Resurrection Project. Accessed July 11, 2021 a AARP-Disrupt-Disparities-Report.pdf (disruptdisparitiesil.com)
2. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003. 
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5. Musa D, Schulz R, Harris R, Silverman M, Thomas SB. “Trust in the Health Care System and the Use of Preventive Health Services by Older Black and White Adults”, American Journal of Public Health99, no. 7 (July 1, 2009): pp. 1293-1299.
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7. Tajuddin, S.M., Hernandez, D.G., Chen, B.H. et al.Novel age-associated DNA methylation changes and epigenetic age acceleration in middle-aged African Americans and whites. Clin Epigenet 11, 119 (2019). https://doi.org/10.1186/s13148-019-0722-1
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