Advancing Health Equity in a Time of Retrenchment: On Equity, Value, and the Work Ahead

This is Tom Lee, Editor-in-Chief of NHM Catalyst, and we're talking today with Lynn Todman about a really challenging and important topic. How do we advance health equity during this difficult period in which national political climate issues pose barriers to this work? I met Lynn when she was working at Coa Health in Michigan, working to build trusting relationships between that delivery system and some of the social economically disadvantaged communities it serves. Lynn gave a terrific talk about this work for NEJM Catalyst back in 2023.

More recently, she has returned to academia and is a professor and the inaugural chair of population health at Meharry School of Global Health. Her values and her goals remain the same, advancing health equity. But we're obviously living in times when many organizations shy away from even mentioning that word. Lynn has thoughts about how to advance this cause in our current context, and I asked her to share them with all of you today.

Lynn, let's start by making sure we're all using the term equity in the same way. Your take on what it is and why it's an important goal? Yes, thank you, Tom, for inviting me to share my thoughts about this topic. Equity has been historically misunderstood, but it is a state in which all people in all communities, regardless of attributes like their physical location, their social status, their cultural identity, are able to thrive and flourish.

We are able to achieve health equity by making sure that everyone in every community has access to the resources and opportunities they need to optimize their health. And this is important, recognizing that different people and different communities have different needs. That's what equity is. Well, in a sense, it sounds like patient-centered care to a clinician like me.

Now, we don't need to spend time talking about why equity is under fire today, however. and we don't need to spend time talking about who is to blame for that. But instead, can you give us a historical perspective? Has the arc of history been moving toward justice for decades, but now has it suddenly stopped?

No, and it hasn't suddenly stopped. As difficult as this moment in time is, it was at some level predictable. Historically, the U.S.

has swung between poles of advancing equity and pushing back on it. So, for instance, the mid to late 19th century, we saw the advent of the 1866 Civil Rights Act, and that established birthright citizenship. We had constitutional amendments that abolished slavery and extended equal protections and due process under the law and other progressive changes. Then we saw backlash.

We saw the rise of Jim Crow laws and legalized segregation. We saw the emergence of literacy tests and poll taxes to limit voting. We saw the institution of the Federal Home Loan Act, which systematically discriminated against certain groups of people with respect to access to funds for home ownership. We saw immigration restriction laws targeting groups.

So we saw this backlash. And then in 1964, we saw landmark civil rights legislation. So reversing nearly a century of restrictive laws. So we saw the desegregation of schools and, you know, health care.

We saw the Voting Rights Act, Fair Housing Act. So we have gone back and forth in this country. And the progressive change that started in 1964 culminated with the election of a president twice who self-identified as African-American and instituted landmark health care legislation. And so now we have this retrenchment back.

And so when you ask the question, has the arc stopped, I would say no. We you know we in the midst of what we do in this country of cycling back and forth between progressive agenda and a more restrictive one Well that is a very helpful perspective because I realize that for baby boomers like me most of our adult life has been part of the pendulum swinging forward and it does not feel good to have the pendulum swinging backward, but your perspective is encouraging. Now, I've heard you use the term equity 2.

0 in some of your talks. Can you explain what Equity 2.0 means? Yes.

Equity 2.0 was a concept coined by John A. Powell at the Othering and Belonging Institute at the University of California at Berkeley. And it goes beyond just closing gaps between healthy and unhealthy populations.

And notably, it doesn't use a particular group as a reference point for the other groups. Instead, it calls for us to aim for universal outcomes. So outcomes for everybody that are optimized through targeted interventions. And this is what the term that we use is targeted universalism, which is how we actualize equity 2.

0. And essentially that means that we establish as a society or as an industry universal goals for everyone. So for instance, we want everyone's blood pressure to be normalized, when everyone wants the A1C to be normalized, et cetera, et cetera. But we recognize that different groups are differently situated and groups will need different things to get to that universal goal.

And so Equity 2.0 and Targeted Universalism, how it's operationalized, is simply setting goals for us as a society and then being clear that different groups need different things to meet that goal and giving them those very specific and unique opportunities and resources to meet that goal. So now I'm getting what you mean by targeted universalism, which sounded like an oxymoron the first time I heard the phrase. But you're suggesting that we should set goals that apply to everyone and then do what it takes to help each person get there, targeting our interventions to do what it takes to be successful in reaching our goals.

Is that what it boils down to? Yes, that's essentially what it boils down to. And as you said a few moments ago, it's not very different conceptually from what health care providers do. I mean, you look at the person in front of you, you assess their needs.

Their needs may be very different from the patients you saw before, the patients you're going to see later in the day. And you tailor your intervention based on this very specific situation, conditions, and needs of the person in front of you. It's the same concept, just expanded to society, to communities, to the larger populations that we care for. Now, I know you have some thoughts about how we use the word value.

Can you expand on them? Yes, I do have some thoughts. So I think a couple of concerns I have. I wonder, and I'm just as an open question, who gets to define who are the arbiters of value?

And right now, it seems to be largely health plans, care delivery systems, policymakers, and regulators. But my question is, where's the patient voice in that? And if you look at the literature, there's generally accepted consensus that the patient voice is desired, but not really effective, not really kind of integrated into how we define value as an industry. And then the question is, where's the patient, the community's voice in that determination of what constitutes value?

And this question in my head is very, very important, especially for nonprofit institutions that have a legal obligation to the communities they serve. So if you don't really understand deeply what patients and communities value? How can you integrate that understanding into how you operate on a day-to-day basis? So that's one of my questions, like who gets to determine what value is and why?

And who actually determines who gets to determine? So that's an open question for me. And then another point is that this concept of value, as we define it in the healthcare industry, is narrow. It focuses on, largely on direct short-term and quantifiable financial returns.

And I would argue that if we limit our understanding of value to these direct short returns we leaving a lot of value on the table Because we know that investments in health equity generally don generate short direct financial returns They generate broader economic and social returns, which are often indirect. They accrue over the medium and the long term. They're often intangible and qualitative in nature. But, and ironically, these investments can have positive effects on the long-term growth and financial condition of healthcare institutions themselves.

So, yeah, my second concern is, are we limiting ourselves when we circumscribe our definition of value to just the financial returns that can be accrued to an investment over the short period of time? And if we continue with that conceptualization of value, it will result in a chronic underinvestment in the care and support for certain people and communities in our society. If we continue to define value in that very limited way, we will not invest in equity-oriented efforts.

And that's my second question about the concept of value as we use it today. Well, you know, I work very closely with Michael Porter, who is, you know, he and Elizabeth Tysberg actually introduced the term value-based care for the first time in 2006, when they wrote their book, Redesigning Healthcare. And Michael's conception of value is so much more consistent with your perspective than with people who think it's about gain sharing and trying saving money and then splitting up the savings.

Michael used to go crazy when he would hear that concept of value, because what he really believed it was about was working together, creating value through you know, good teamwork and, you know, co-creative collaborations to optimize outcomes and then try to do that as efficiently as possible. Optimizing outcomes was goal number one. And I am completely sure that he would have embraced the concept of targeted universalism, as you described it. But I think that pressing this issue to help remind people that value is not about financial issues, number one.

It's about outcomes, number one, and efficiency, number two. Now, let's turn to another aspect of language, because language is so important. Back when I was in college, I actually met the playwright Lillian Hellman, who you may recall, refused to name names to Joe McCarthy's House Committee. You won't recall it, but you may have read about it.

And she famously said, I cannot and will not cut my conscience to fit this year's fashions. I think there are a lot of us in health care who feel like Lillian Hellman and feel like you. We feel like we can't deliver good health care if it's not equitable, because it's not going to be patient-centered if we're not pursuing the same values as you're pursuing. So in our use of language during this very difficult time, what is your advice?

Do we lay low or do we find ways to push so that maybe the pendulum can start to swing back in the other direction sooner rather than later? Yes, Tom, I'm really glad you invited me to do this podcast because it gave me time and space to think deeply about that question, which is a really important question now. And where I've landed is, as you might have predicted, we definitely don't lay low. You know, we still do the work.

And there are some concrete things that we can do. For one thing, we have resources and opportunities to do this work that we didn't have 100 years ago or 50 years ago. We have a much stronger legal policy institutional framework that can be used to push for change now it being it being ravaged but the framework is still there we have something that we can work with unlike what we had 100 or 50 years ago um we have an involved set of norms and values and beliefs in this country about rights and opportunities that people and communities are entitled to a very different set of values and norms and beliefs than we did 50 or 100 years ago.

And we see that actualized every day. We have a whole new set of platforms and actors and coalitions to advance this work. We have research and data that we didn't have 50 years or 100 years ago. We have a more diverse, informed, engaged, and mobilized electorate compared to 50 and 100 years ago, communications infrastructures.

We have a lot of things going in our favor that we didn't have 50 and 100 years ago that we can build on to push the pendulum back in the other direction. And that's part of the reason why I'm optimistic. And yes, every day, every week, we see evidence of the infrastructure, the norms, the research being attacked, but there's still a substantive enough body of resources and opportunities for us to leverage to keep pushing this work forward. And we have places that are still doing the work.

So we have places that are still doing the work across the country. And take Meharry School of Global Health, where I'm at right now. The school is 150 years old. It lived through Jim Crow, the retrenchment, the Civil Rights Act.

It's going to continue to move forward. And we are continuing to move forward. So we're doing work, a heart initiative to address cardiovascular disease in communities suffering from high rates of heart-related morbidity and mortality. We're focusing that work in rural communities, in African-American and Latino communities.

We're continuing our work on disparities in maternal and child health and starting work on disparity risks posed by AI, doing lots of research on autoimmune kidney disease of people and people of African descent, making human cells resistant to HIV infection, lots of work that's still going on at Meharry and other places. And if listeners want, you know, other concrete ways to continue the work, I would suggest engaging with institutions like Meharry, who are still doing the work, we still say equity.

We still talk about disparities and inclusion. And that would be kind of my response to your question. Do we lay low? No, we don't.

We keep going. Well, you make me feel optimistic, Lynn, in a time where optimism may seem like it's in short supply, But your long-term perspective is valuable. And I have to say you make me feel glad to be in healthcare because the work of healthcare is inherently good. We are trying to ease people's sufferings.

We can't do our work without treating everyone with respect and doing our best for them. And it inherently is about the pursuit of equity. I am sure that in the years ahead, I will be learning from you and your colleagues at Meharry and wherever else you're speaking and working about how we can stay oriented toward doing the right thing for our patients and for our society. So thank you so much.

And I look forward to the next time that we get to talk together and hopefully share some more insights with our audience at NGM Catalyst. Thank you, Tom, for this opportunity to share my thoughts. I really value and appreciate it. Is race a medical fact or a flawed assumption?

What happens when medicine gets race wrong? I'm Rachel Gottbaum, and this is Intention to Treat from the New England Journal of Medicine. Join us for Season 2, The Race Equation, where we examine assumptions about race that are harming patients. Listen and subscribe to Intention to Treat wherever you get your podcasts.